Quality Accounts 2018-19
This Quality Account covers the period 1 April 2018 to 31 March 2019
101 Contents
Part 1 – Letter from our Chief Executive
Part 2 – Our Priorities About us Our patient safety priorities Quality Account priorities – looking back over the last year Quality Account priorities - Looking forwards to this year Statements of assurance from the Board of Directors
Part 3 – Other information Reporting against core indicators CQC CQUIN Duty of Candour Additional considerations
Annex 1: Statements from commissioners, local Healthwatch organisations and overview and scrutiny committees Annex 2: Statements of directors’ responsibilities for the quality report
102 Glossary of terms Assessment and Comprehensive ACE OPU Evaluation Older Person’s Unit MSK Musculoskeletal
ACS Acute Coronary Syndrome National Safety Standards for Invasive NatSSIPS Procedures ARK Antibiotic review kit NEWS National Early Warning Score AKI Acute Kidney Injury NHS National Health Service
ASP Antiphospholoipd Syndrome National Health Service England / NHSE/I Improvement
BANES Bath and North East Somerset National Institute for Health and Care NICE Excellence BIU Business Intelligence Unit NTC Neonatal Transitional Care BAPM British Association of Perinatal Medicine PALS Patient Advise and Liaison Services
CCG Clinical Commissioning Group PROMS Patient reported outcome measure
C.diff Clostridium difficile Q1 Quarter 1 (April, May, June)
CQC Care Quality Commission QI Quality Improvement
Quality, service improvement and CQUIN Commissioning for Quality and Innovation QSIR redesign DTT Decision to Treat RCA Root Cause Analysis
EAP Employee Assistance Program RCEM Royal College of Emergency Medicine
National Emergency Care Intensive Support ROP Retinopathy of Prematurity ECIST Team RUH Royal United Hospitals E. Coli Escherichia coli
ED Emergency Department RTT Referral to treatment FFFAP Falls and Fragility Fracture audit program SAU Surgical Admissions Unit
FFT Friends and Family test SHMI Summary Hospital level mortality Indicator FLS Fracture Liaison service SJR Structured Judgment Review Health Education England South West HEESWSN Simulation Network SKIP Sepsis and Kidney Injury Prevention HMSR Hospital Standardised Mortality Ratios SSNAP Sentinel Stroke National Audit Programme HSJ Health Service Journal SPR Specialist Registrar SSB Sugar sweetened beverage IM&T Information Management and Technology
Local Safety Standards for Invasive STP Sustainability and transformation plan LocSSIPS Procedures SWAST South West Ambulance Service MAU Medical Admissions Unit UTC Urgent Treatment Centre MDT Multi-Disciplinary Team
MRSA Methicillin Resistant Staphylococcus Aureus VTE Venous thromboembolism
MOP Minor Operating Procedures West of England Academic Health WEAHSN Science Network
103 Part 1 Letter from our Chief Executive
104 Quality Accounts 2018-19
Part 1: Chief Executives Statement –statement on quality
The Board of Directors is committed to providing services of the highest quality to our patients, their families and carers and to being a listening organisation that is responsive to individual needs. As an organisation we strive to place patient safety and service improvement at the heart of everything we do. We aspire to be a good partner: innovative, collaborative and passionate about patient experience, and we work closely with service users, their carers, our partners in other agencies and third sector colleagues to deliver integrated care across our local system.
The Trust values: Everyone Matters, Working Together, Making a Difference are at the core of everything we do for our patients, and represent our aspiration for the type of hospital we strive to be.
The Trust identifies a series of quality priorities each year, and I am pleased to report that we made substantial progress against our quality priorities for 2018/19 as described in the accounts below.
The Trust is proud of its dedicated staff, and I am delighted to report that several teams have been recognised for their outstanding work and nominated for a number of awards in 2018/19. This reflects the commitment of our staff to deliver the highest quality of care.
This has included, amongst many others: - Our Home First partnership team named as regional winners in the National NHS70 Parliamentary Awards. The Home First scheme was launched by the Trust in 2017 and aims to reduce the length of stay for patients who are clinically well enough to leave hospital, but who might need extra support to return to their usual place of residence; The Royal United Hospitals’(RUH) specialist Sleep team, and Pulmonary Hypertension care service both shortlisted in this year’s British Thoracic Society awards; Three pioneering projects from the Trust shortlisted as Health Service Journal (HSJ) Award finalists which celebrate excellence and innovations throughout the health service, including a patient safety project introducing screening tools to identify patients at risk of sepsis and acute kidney injury (AKI) and a nomination for establishing a national quality improvement training programme for staff at the RUH. Staff from our Project SEARCH team were also recognised in the Widening Participation category and went on to win at the Awards Ceremony on 21st November 2018. This category recognises organisations who make efforts to recruit from groups and communities who aren’t well represented in the NHS workforce, have had trouble finding employment elsewhere or that have specific needs and
105 experiences. Project SEARCH is a one-year course supported by the Trust, in partnership with Virgin Care and Fosse Way School, which helps students with learning disabilities to gain work experience and find jobs; The Trust received a commendation at the 2018 Quality in Care (QiC) Diabetes Awards for its work in helping children manage their diabetes; and Our multi-award winning Frailty Flying Squad were named winners for the 5127 Award at the 2018 Fab Awards on 17-18th November. The pioneering specialist team of doctors, nurse practitioners and therapists work in the Trust’s Emergency Department and Medical Assessment Unit and identifies older patients who, with some intensive assessment and treatment, have the opportunity to return to the community rather than being admitted to hospital.
Like many other acute trusts this year, we have been facing huge pressures on our Emergency Department (ED) with increasing admissions and a higher than the national average elderly population. With our partners we have focused on reducing long lengths of stay in hospital and this year we have seen a month on month reduction in the number of patients staying over 21 days in hospital (24% reduction from 2017/2018). This means that patients leave hospital when they are ready to and avoid any unnecessary delays. We remain committed to delivering high quality safe care to our patients at all times, and we recognise the impact that periods of continued pressure have both on our patients and staff. I would like to take this opportunity to thank our staff for their dedication and support throughout the year.
We also continue to work in a more efficient and effective manner, make savings and meet efficiency targets while still providing quality care to our patients. The Trust has established a programme of work that will support us in the delivery of sustainable highest quality services to our patients and enable us to be an employer of choice through our particular focus on staff engagement and wellbeing.
This exciting four-year programme is called "Improving Together" and will focus on creating a culture of service improvement across our hospitals at all levels, and ensuring that front- line clinical staff are empowered to effect change and improvements to the services they provide. The work will deliver our vision and key objectives for patient safety and quality, staff satisfaction and sustainability.
I confirm that to the best of my knowledge the information in these quality accounts is accurate, and I hope that you find it interesting and informative. I would welcome any feedback you would like to share. Signed:
James Scott Chief Executive
Date: 10/05/2019
106 Part 2 Our Priorities
107 Part 2: Priorities for Improvement and statements of assurance from the Board of Directors
2.1 About Royal United Hospitals Bath NHS Foundation Trust
The Royal United Hospitals Bath NHS Foundation Trust (the Trust) primarily provides healthcare services to around 500,000 people across Bath and North East Somerset, Wiltshire, Somerset and South Gloucestershire. Our dedicated workforce of clinical and non- clinical staff deliver a range of high quality services from our main major acute hospital site in Combe Park in Bath, the Mineral Water Hospital in central Bath, and a number of community birth centres and other outpatient centres across the region.
The Trust provides around 760 beds, a comprehensive range of acute services, including medicine and surgery, services for women and children, accident and emergency services, specialist rehabilitation services, and diagnostic and clinical support services.
The Trust, in partnership with local universities and colleges, also plays a significant role in education and research. Doctors, nurses and many other healthcare professions have been with us as students and have stayed with us as qualified staff. This focus on learning supports innovation and improvement in the excellent care provided for our patients. The Trust continues to work collaboratively with system partners across the local sustainability and transformation plan (STP) to improve and transform services for our patients.
2.12 Why are we producing a Quality Account?
All NHS Trusts are required to produce an annual Quality Account to provide information on the quality of services to service users and the public, as part of the drive across the NHS to be open and honest.
The Trust welcomes this opportunity to demonstrate how well we are performing, taking into account the views of service users, carers, staff and the public, and comparing our progress against the previous year and where we can, against national performance. We proactively use this information to make decisions about our services and use it as an opportunity to identify areas for improvement.
In this year’s Quality Account we have set out how we have performed against The Trust’s patient safety priorities as well as the national priorities, setting out plans for improvement where we have not met any of these priorities.
For 2018/2019 we set four quality account priorities under the categories of safe care, effective care and patient experience. This Quality Account will explain why we chose these priorities and will summarise how we have performed against them and any improvements we have made. Our Quality Account Priorities 2019-20 have been aligned to our 2018-2021 Strategy which is built around our five True North Goals which reflect out Trust values:
108 2.13 How do we improve Quality?
Providing high quality, safe, effective, patient centred care is at the heart of all we do. Our vision is:
To provide the highest quality of care; delivered by an outstanding team who all live by our values
Quality improvement, leadership and governance Our approach to quality improvement and governance is led by our Director of Nursing and Midwifery and Medical Director. The Medical Director chairs Quality Board, which reports to Board of Directors, and the Director of Nursing and Midwifery leads the Trust’s Quality Improvement Centre, which brings together staff working in patient safety, risk management, quality improvement, clinical audit and patient experience.
109 Quality improvement approach
In 2018 the RUH continued to deliver a number of improvement training programmes: Flow Coach programme Quality, Service Improvement & Redesign (QSIR) Practitioner QSIR Fundamental These have built on our capability and capacity to improve safety and experience for our patients and staff.
In 2018/19 QSIR was formally evaluated by the University of West of England: 100% candidates would recommend the course to colleagues’ 96% reported increased confidence in tackling problems when implementing improvements’ 93% expressed increased confidence in helping others with Quality Improvement issues.’
The evaluation concluded that “A legacy of QI ability and implementation now exists amongst participants and the associated workforce”
The RUH QSIR work was also recognised nationally in 2018 being shortlisted as finalists for the HSJ Awards, with the judges commenting:
“Exceeded all goals despite challenges and evidence of the impact of improvement projects was clearly demonstrated. High value due to scale of project and involvement across the organisation”
In 2018 the RUH commenced the Improving Together Programme; an organisational development programme to achieve sustained performance by aligning strategy, people, process and culture. One work stream within the programme is the Bath Improvement System which is a system of routines, behaviours and tools which ensure daily continuous improvement and performance excellence.
Our focus for 2019/20 will be the implementation of the Improving Together Training Strategy that describes how we will build on the internal capability – skills, tools, mind-sets and establish a common improvement methodology and shared improvement language across the Trust. All existing quality improvement courses will come under the umbrella of Improving Together and all staff will receive training/coaching in the necessary tools, routines and behaviours to allow them to carry out improvements in their own areas. There will be a clear learning pathway for a range of staff to develop their competencies in quality improvement to an advanced practitioner level.
The Improving Together Programme Board monitors key performance indicators to track progress towards implementation of Improving Together and outcomes seen from teams who have completed training.
This strategy supports the national framework described in Developing People, Improving Care.
110 2.14 Patient Safety Priorities 2018/19
The Trust is committed to providing safe and compassionate care and we have established a culture of improving patient safety through our patient safety priorities. The Trust patient safety priorities are set out in our patient safety triangle and consist of our five top patient safety priorities and four executive sponsored patient safety priorities.
Each patient safety priority has an established clinical leader, and an executive sponsor, who are responsible for setting the work-plan with agreed process and outcome measures. These are reported to Quality Board, which is chaired by the Medical Director, and to the Board of Directors.
The Trust actively participates, contributes and is leading some of the work aligned to the West of England Academic Health Science Network (WEAHSN). The RUH is fortunate to host the WEAHSN Network. The WEAHSN is managed by a Partnership Board which includes representatives from the other AHSN member organisations. The WEAHSN patient safety collaborative is chaired by our Chief Executive and the Director of Nursing and Midwifery is the Trusts representative which helps to ensure we can align the Trust’s patient safety priorities to national priorities and that we benefit from collaborative working. The four patient safety priorities are: 1. Falls 2. National Early Warning Score (NEWS) 3. Clostridium Difficile infection 4. Sepsis
Falls
The Falls Prevention pathway is the framework for the Falls improvement work. In September 2018 the Falls Steering group held an event following a review of the pathway (originally launched in June 2017). Representatives from each ward attended the relaunch which featured work stations including falls prevention documentation, enhanced
111 observations process, clinical assessment including recording lying and standing blood pressure, environmental risks and post falls care.
The Falls eLearning programme is being developed led by two subject matter experts from the Falls Steering group. The programme is aimed at all patient facing staff and launched at the end of February 2019. Following the successful bid to Health Education England South West Simulation Network (HEESWSN) the Falls Simulation training project commenced in April 2018. The aim of the project was to improve the knowledge of the multidisciplinary teams to support the reduction of in-patient falls. The project is funded until March 2019 and to date 182 staff members in nine wards have received training. Other outputs from the training have included: “Fred is falling” workbooks, lanyard wallets with clinical information reminders and guidance and a short video capturing the teaching given as part of the Simulation project. To support the awareness in the use and training of the Falls retrieval kit (Hover jack) a trolley dash to all wards took place September 2018. In addition to complement training a video has been developed to raise awareness and knowledge in the use of the kit.
All patient falls (defined as an event which results in a person coming to rest inadvertently on the ground or floor) are reported via DATIX the incident reporting tool. The Falls Steering group monitors all falls within the Trust; this includes reviewing the results of all root cause analysis (RCA’s) investigations into falls that have occurred. This process enables us to learn from incidents, identify themes and trends and look for improvements. A review of the Serious Incident investigation process for Moderate and above harm falls was completed in January 2019. A more effective approach to falls investigations has been developed to focus on prevention rather than investigation. This consists of a falls huddle which takes place in the clinical area where the fall has occurred to identify if learning is already included if the falls work plan or if there is new learning around the cause of the fall. New learning would trigger a comprehensive root cause analysis (RCA).
The Healthcare Quality Improvement Partnership benchmark is 6.63 falls per 1000 bed days (October 2015): The Trust has performed under the benchmark for all falls per 1000 bed days for the last 3 years. Comparing the period April 2017 - January 2018 to April 2018 - January 2019 shows a 13.8% reduction in Inpatient areas in the total number of falls. Of the falls in the same periods 2017 -2018 3.1% of the falls were Moderate and above harm compared to the period 2018 - 2019 where 2.3% were Moderate and above harm.
National Early Warning Score (NEWS)
The aim of the National Early Warning Score (NEWS) work stream is to ensure that NEWS is reliably and accurately used when monitoring adult patients’ vital signs, for example blood pressure, pulse and respiratory rate, that care is appropriately and reliably escalated and correct actions are taken to ensure optimal care for the patient.
A Deteriorating Patient campaign took place April 2018. A key part of this was tea trolley training to provide key messages around NEWS, Sepsis, fluid balance and escalation of the deteriorating patient. The training was delivered to 148 members of staff in 23 areas. In line with national requirements from NHS England a new chart was developed to support the adoption of NEWS2 which included a new parameter of assessment for confusion and
112 two scoring systems for oxygen saturation levels. The chart was launched Trust wide in November 2018 alongside a programme of training and awareness.
In November 2018 a Deteriorating Patient proforma was developed and launched as a prompt to aid nursing staff when escalating the deterioration of a patient triggered by a raised NEWS2, this also includes a section for completion by medical staff detailing their assessment and action plan post patient review. The NEWS 2 eLearning package is under development with a launch planned for March 2019.This will complement training delivered by the cascade trainers at ward and department level. Towards the end of 2018 the NEWS work stream has linked with the Sepsis and AKI work stream to develop the Deteriorating Working group. To further support this joint working a model for a combined Deteriorating Patient team in all wards and departments has been developed.
NEWS2 work stream members are actively supporting the project for an electronic observation system. The eObservations project board has been established with fortnightly meets scheduled, in addition a weekly mobilisation team has been established. Devices to support the implementation are being sourced with the first test ward aiming to go live March/April 2019.
Clostridium difficile infection
The Trust continues to work to reduce the number of Clostridium difficile infections using an improvement plan with multidisciplinary input. The improvement plan includes antimicrobial stewardship including the introduction of ARK (antibiotic review kit), a focus on improving environmental and equipment cleanliness and learning from root cause analysis investigations. Infection prevention and control education continues to be a focus with significant improvement across the divisions working towards the 90% compliance target. All positive Clostridium difficile samples are now ribotyped, regardless of whether the toxin test is positive. Ribotyping is a molecular technique undertaken in a laboratory to identify the characteristics of a particular strain of bacteria. This has helped to identify our predominant strains and also to assist with investigation of potential outbreaks, however having two of the same ribotype in an area does not necessarily indicate that there has been cross contamination.
The 2018/19 trajectory for Trust attributed Clostridium difficile infections was 21 cases. During the reporting period there were a total of 32 reported via the Public Health England Healthcare Associated Infections Data Capture System. In 5 cases there were no lapses in care identified and it was agreed by the Commissioners that these cases would not count towards the year-end total, resulting in 27 cases. There are another 4 cases that have been submitted to CCG Clostridium difficile panels, the result of these appeals are not yet known. If they are all agreed this will take the year-end total to 23 cases.
NHS Improvement were due to make a supportive visit to the Trust in February 2019 to review progress against the improvement plan however this has been delayed due to unavailability of one of the visitors. The visit has been rescheduled to take place in June 2019
113 Sepsis and Acute Kidney Injury
Sepsis and Acute Kidney Injury (a sudden deterioration in kidney function) remain the commonest cause of deterioration in patients in hospital as well as being common reasons for admission. If not identified early, both can result in a poor outcome for patients. They are both national safety priorities and remained important priorities for the RUH in 2018/19. We continued our work to improve early recognition of these conditions by embedding the tools to identify Sepsis early. These are based on a change in the patient’s vital signs as measured by the national early warning score, and we have continued to ensure all staff have received adequate training. Sepsis and AKI training have been established in formal training as ‘essential for all clinical staff’. An e-learning tool has also been developed.
However, maintaining levels of screening has been challenging, we have developed a very early screening tool to ensure we pick up changes as soon as possible, but without electronic triggers it has been difficult to achieve a compliance of more than 80%. Despite this the sepsis team have continued to support all the clinical areas, and 89% of patient with Sepsis have received antibiotics within an hour of diagnosis. We have also particularly improved screening for children and maternity patients, with over 90% at risk children being screened for sepsis and 100% mothers with Sepsis receiving antibiotics in an hour from diagnosis.
The sepsis work has resulted in improved management of all patients with infections and this is demonstrated by a national dashboard produced in 2018 demonstrating improved outcomes for patients with infection. This has shown a 17 % reduction in mortality, a 12% reduction in Intensive care bed days and a 10% reduction in length of stay for patients at the RUH with infection.
In 2018 we linked the Sepsis and Acute Kidney Injury teams together to ensure the work was aligned and the Sepsis Nurses also supported early detection of decreasing kidney function while a patient was in hospital, improving early detection of any clinical deterioration in a patient’s condition. This has resulted in a 25% reduction in the incidence of AKI acquired during a hospital admission, and a reduction in length of stay for all those with AKI by 6 days. Mortality rates for those with an AKI also decreased by 8%.
The work on Sepsis and AKI over the last few years has therefore, significantly improved outcomes for patients by our focus on very early recognition of any change in a patient’s condition, and this was acknowledged nationally with the Sepsis/AKI inpatient work being shortlisted as a Finalist in the Patient Safety category of the HSJ Awards in 2018.
In 2018 the RUH Sepsis Lead also supported establishment of a Sepsis Support Group in Bath, coordinated by the UK Sepsis Trust, which meets several times a year providing support for those who have had Sepsis.
2.15 Quality Account Priorities 2018/2019 and 2019/2020
Choosing our Quality Account priorities is important to us and our aim is to ensure the chosen priorities are ones which will make a real difference to our patients.
114 We have engaged with our staff, the Governor Quality working group, the Trust’s Council of Governors, the Patient and Carer Experience Group, the Board of Directors, and our Clinical Commissioning Groups to determine the priorities. We agreed four priorities and for each priority, we outline below why it is important to us as a Trust and for our patients, and identify specific indicators we aim to achieve and how progress will be measured. Our priorities for 2019/20 focus on improving pathways of care and ensuring we are continuously listening and learning and making improvements as a result of our patient feedback. The Governors Quality working group were particularly keen to endorse and support taking forward continuity of carer whilst the Patient and Carer group were very supportive of learning from patient feedback as a quality priority’.
The next two sections will set out our progress against the four Quality Account priorities chosen for 2018/ 2019 and describe the four priorities agreed for 2019/2020. Table 6 in section 2.17 below, demonstrates how each of the four chosen priorities relates to Patient Safety, Patient Experience and Clinical Effectiveness, in addition to how each of the priories complements our True North goal
The Quality Account priorities and the progress will continue to be monitored through Quality Board, which is chaired by the Medical Director.
2.16 Priorities for improvement - looking back over last year
Overview 2018-19
Priority Aim Achieved Partially achieved Priority 1 Transitional Care
Priority 2 Reducing the waiting time for diagnostic tests Priority 3 Ensuring our patients with a fractured neck of femur go to theatre within 36 hours of admission Priority 4 We will listen to patients and carers and use their feedback to improve Services
Priority 1: Transitional Care
Neonatal Transitional Care (NTC) aims to keep mothers and babies together and help with safe and effective parenting, attachment and the establishment of infant feeding. NTC supports new mothers of babies with increased care needs.
Why it is important:
As far as possible every newborn baby should be with their mother. Mothers and babies have both a psychological and physiological need to be together at birth and in the hours and days that immediately follow; this can reduce harm from later health concerns.
115 It is recommended that all healthy mothers and babies, regardless of feeding preference and method of birth, have uninterrupted skin-to-skin care beginning immediately after birth for at least an hour and/or, for breastfeeding women, until after the first feed.
Keeping mothers and babies together on a postnatal ward allows them to have extended skin to skin care which will reduce the stress levels in the baby, provides protection against infection and assists the babies positioning for breast feeding. Furthermore there is increasing evidence that early emotional interactions between a baby and their parents, particularly the mother, are fundamental to brain development, subsequent success, life chances and the ability to form strong loving relationships.
What we said we would What we did do By providing services, Introduced a Transitional Care pathway, using Flow clinical pathways and coaching methodology, a methodology where both staffing models that keep staff and service users meet in a “Big Room” and mothers and babies discuss a quality improvement pathway and how to together deliver it. A Neonatal Nurse is allocated to work on Transitional Care 24 hours a day. The Advanced Neonatal Nurse Practitioner reviews these babies daily and decides on care plan and discharge plan. All babies reviewed at point of admission as to where the most appropriate location of care is, trying always to maintain mother and baby together. Introduction of Kaiser Early Onset Sepsis Tool which determines the need for a baby to receive antibiotics. This tool reduces the number of babies who receive antibiotics British Association of Perinatal Medicine (BAPM) hypoglycaemia guideline introduced Reduce the percentage of Table 1 demonstrates the percentage of live term births babies born a few weeks admitted into the neonatal unit and demonstrates that we have before or after the expected consistently over achieved the target of 9% (2% below date of delivery admitted to baseline by March 2019). the neonatal unit from 11% Table 1: (Baseline from 2016) to 9% RUH, Local Live Births Term Admissions by March 2019 Neonatal Number Percentage Unit Live Births Q1 April-June 1162 60 5.2% Q2 July- Sept 1171 67 5.7% Q3 Oct-Dec 1120 65 5.6% Q4 Jan-March 1077 Figure outstanding at time of report
Table 2: Admission criteria to Transitional Care Transitional care First Wave of 34.0-35+6 weeks gestation implementation 4 hourly observations Gestational age Current weight 1.8 kg or above at birth 4 hourly observations
116 Second Wave of Require regular tube feeding but are implementation otherwise well Feeding requirements Infant of diabetic Requires increased monitoring or mother management of low blood sugars. 34-35+5 weeks gestation requires risk assessment. Infection Requires intravenous antibiotics Jaundice Frequent serum bilirubin blood test at least 8 hourly and/or requiring double phototherapy Neonatal Babies requiring treatment for Abstinence neonatal abstinence syndrome due Syndrome to maternal substance use, following risk assessment of mother and baby.
How we will continue to work with this priority
Ensure British Association of Perinatal Medicine hypoglycaemia guideline is embedded with audit data to back that the guideline is being used Continue with Kaiser Early Onset Sepsis Tool to enable a reduction in the number of babies being admitted requiring antibiotics and audit to back it up Review and audit all term admissions to the Neonatal Unit looking at the appropriateness of the location of care
Achieved
Priority 2. Reduce the waiting time for diagnostics tests.
What is the priority?
Reducing the time taken to get diagnostic invasive procedures for inpatients who are not on wards that specialise in those procedures. This priority will look specifically at patients who are waiting for invasive heart tests (i.e. coronary angiograms) and non-invasive tests to examine the digestive tract (i.e. gastric endoscopies)
Why is it important?
Patients can wait a long time to have some invasive diagnostic tests; this is especially the case if they are not being cared for on a ward that specialises in that clinical condition. Concentrating on these patients, who are waiting for an angiogram or an endoscopy we will be able to improve the timeliness of the test and reduce the total time that the patients spends in hospital waiting for the test.
117 Cardiac diagnostic tests
What we said we What we did would do Patients would be An improved model of for the movement of patients awaiting moved to their cardiac procedures has been developed. This includes the use specialty wards i.e. the of an Acute Coronary Syndrome (ACS) nurse and acute cardiac ward as early physician with cardiology speciality knowledge and skills to as possible review patients on the Medical Admissions Unit and Medical (ONGOING) Short Stay unit to ensure that the correct patients are referred on for coronary angiography. These patients are then clinically risk assessed and placed on the waiting list in an appropriate order according to the severity of the patients risk for further chest pain. This list is shared with the Cardiac ward and the clinical site team – who coordinate patient flow through the hospital, Medical Admissions Unit, and Medical Short Stay.
Across the other adult wards medical staff are encouraged to attend a dedicated session where they can discuss any cardiology concerns about their patients with the cardiology consultants. This ensures that patients are transferred up to the Cardiac ward beds in an appropriate and rapid manner that is balanced with patients being urgently admitted into the hospital from outpatient clinics, the emergency department or who no longer need the intensive support provided of the Coronary Care Unit. Consultants and The input of the specialist ACS nurse and doctor working in Medical Nurse Medical Admissions Unit has resulted in improved prioritising of Practitioners would be patients to ensure that the correct patients are moved to a proactive in the Cardiac ward bed. This pathway remains a priority across Acute management of Medicine and Cardiology directorates. ensuring these patients were in the Additionally the dedicated cardiology session is actively used by correct beds medical staff to identify and prioritise patients. (ONGOING) Treatment would begin The above actions help to ensure that patients are seen in the in a more timely most appropriate order according to clinical need. manner Work has been completed to ensure that information is given to (ONGOING) the Cardiac Catherisation laboratory and the Cardiac ward from Medical Short Stay/ Medical Admissions Unit and other wards across the Trust, to provide accurate and pertinent information to help with this prioritisation. Reduction in the The time patients spend on the Medical Short Stay Unit has number of cardiac been reduced to allow a more rapid flow through the beds and patients not on a ward where possible patients are transferred directly from Medical of that Admissions Unit to the Cardiac ward. Speciality (ONGOING) In Quarter 4 2018/19 work has begun to incorporate the use of Medical Short Stay beds as chest pain beds creating a pathway for patients to move through from Emergency Department to Medical Short Stay and then to the Cardiac ward if their clinical condition requires cardiac angiography or to stay on Medical Short Stay if this is more appropriate.
The pathway for This continues to be a work in progress and will continue to be patients waiting for an improved upon with the work shown above.
118 inpatient angiogram who are not waiting on Systems are being put in place to collect data to evidence this the improvement. Cardiac ward will be improved with 100% of patients transferred to the Cardiac ward within 48hrs. (ONGOING)
How we will continue to work with this priority?
Develop the chest pain pathway between Emergency Department and Medical Short Stay. Develop a business case for the role of a dedicated Acute Coronary Syndrome nurse to work with Emergency Department/ Medical Admissions Unit/ Medical Short Stay/ Cardiac ward. Continue to improve the pathways for patients who require coronary angiograms and general cardiology input including specialist tests across the Trust. This will include the use of the seated recovery lounge within the Cardiac Catheterisation Laboratory as well as the use of beds on the cardiac ward. Work with the Clinical Site team to highlight the number of patients outlying on wards across the Trust that require cardiac angiography
Gastric diagnostic test
What we said we What we did would do Patients would be All emergency gastroenterology patients are sent to the moved to their endoscopy department from Emergency Department, Medical specialty wards i.e. the Assessment Unit and Surgical Assessment Unit and then admitted gastroenterology from the department onto Haygarth Ward after their investigation. ward as early as These patients are identified throughout the day by the Medical possible Nurse Practitioner and/or Discharge Facilitator liaising with the (ONGOING) above departments and the Clinical Site Team in order to move patients onto the ward and to avoid admission onto an outlier ward Consultants and The nurse practitioner and discharge facilitator liaises with Medical Medical Nurse Assessment Unit senior nurse early each weekday morning to Practitioners would be manage and allocate the forthcoming beds on Haygarth to proactive in the gastroenterology patients within Medical Assessment Unit / management of Emergency Department ensuring these patients were in the correct The nurse practitioner and the senior nurse on Haygarth ward also beds review patients on the ward to identify any patients who can be (ONGOING) transferred to a more appropriate bed in order to make capacity for admissions from endoscopy department and Medical Assessment Unit or patients from different wards that may need to come to Haygarth ward. Treatment would begin Referrals for endoscopies have been transferred to the Trust’s in a more timely electronic computer system (Millennium) since August 2018. This manner replaced the paper faxed referral system and has reduced the risk
119 (ACHIEVED) of delays. Since August 2018 there has not been incidents of missed referrals. Reduction in the The consultants have changed their practice to ensure there is a number Gastroenterologist consultant of the day available to see all gastroenterology gastroenterology patients who are not on the gastroenterology patients not on a ward ward (outliers) to ensure they are reviewed daily, including of this weekends. Therefore any patients awaiting a procedure will be Speciality seen by a gastroenterologist daily. Haygarth has an outlier board (ACHIEVED) and the consultant will add patient details to this and liaise with the nurse in charge when they identify a patient who needs to come to the ward. Patients waiting for an Between August 2018 (when the referral system was transferred inpatient endoscopy from fax to electronic on millennium) and February 2019 the who are not on the average time for endoscopy procedures were 21 hours from gastroenterology ward referral. With the exception of September 2018 where the average will receive their scope time was 32 hours, however this was due to an increased number within 24 hours of the of patients being referred (19 patients were referred in September, request. the average is 13 patients referred per month). Of these 19 (ACHIEIVED) patients referred, 18 were confirmed as needing an endoscopy procedure when reviewed by the gastroenterologist. Whilst we have successfully achieved against 3 of the 5 standards that we set ourselves within the gastroenterology part of this quality priority, we did not achieve against any of the standards within cardiology. We recognise that our journey for improvement continues, therefore we acknowledge limited achievement for this quality priority
The improvement has been in the reduced risk of referrals being delayed due to missed referrals since the referral system was transferred to an electronic system in August 2018 (there has not been any missed referrals since August 2018). Table 3 below, shows the numbers of referrals for endoscope, numbers of actual procedures performed and the reduction in time from referral to procedure.
Table 3:
Endoscope Procedures 35 Referrals for 32.28 Endoscopy 30 Procedure 25
20.7 Number of 20 19.14 19.86 17.67 Procedures 15 15.83 13 10 Avg Referral 5 To ScopeTime 0 (Hours) Aug Sep Oct Nov Dec Jan Feb 2018 2019
120 How we will continue to work with this priority
The medical nurse practitioner and discharge facilitator will continue to liaise early on each day with the Medical Assessment Unit senior nurse to transfer identified gastroenterology patients to Haygarth Ward. The outlier patients will continue to be reviewed by a gastroenterologist daily (7 days/week) and liaise with the ward and bed manager to transfer to Haygarth ward. Due to the electronic referral system now in use on millennium for in -patient endoscopies, the risk of any delays for procedure is reduced, therefore we will continue to provide an average wait time each month for inpatient endoscopies of below 24 hours. The plans are currently with the Information Management Technology team to replace paper referrals for other gastroenterology procedures, such as colonoscopies and flexi sigmoidoscopies with millennium referrals of which we can monitor the timeliness of these referrals too.
Partially achieved
Priority 3: Ensuring our patients with a fractured neck of femur go to theatre within 36 hours of admission
Why it is important:
The timing of surgery is an early marker of a patient’s progress following a hip fracture. Patients who receive surgery within 36 hours are more likely to have improved outcomes post operatively. These include:
Reduced Mortality Reduced length of stay Reduced post-op complications
However, as the population ages there are an increasing number of patients who would not benefit from surgical intervention, and who are therefore managed conservatively.
There is also an increase in the number of patients admitted with a hip fracture on the same day putting pressure on trauma theatre capacity.
What we said we What we did would do Review and The Hip fracture proforma has been revised by both the redesign the patient orthogeriatrians and Emergency Department doctors. pathway to reduce duplications and All paperwork has been reviewed and deemed to be relevant so avoid unnecessary no further changes were necessary. A process mapping session Delays took place with all the relevant parties (Consultants, Emergency (ACHIEVED) Department Consultants, Therapists) to look at all paperwork and reduce where possible any unnecessary delays. Improve expertise in X-Ray protocols have been written and shared with diagnosis consultants/junior doctors. This has been shared through junior (ACHIEVED) doctors training and at Orthopaedic Governance meetings with
121 the Consultants. Modifying the angle at which the affected limb is x-rayed has been identified in literature as more accurately categorising. This view would negate the need of a second scan if the hip fracture is not initially visible. Ensure that patients The lead doctor for hip fractures has produced guidelines for are well enough to acceptable reasons for hip fracture operations to be delayed on receive an medical grounds including issues with blood thinning treatments anaesthetic and and these have been shared with teams. have an operation The Anaesthetists have been asked to work with anaesthetic through medical trainees in an attempt to reduce the time taken to anaesthetise optimisation the patient, as prolonged periods of time can impact upon the (ACHIEVED) number of cases performed on each list.
Hip fracture surgery is now scheduled where possible to be undertaken in the morning, as this ensures that as many patients with hip fractures are operated on as possible each day reducing the likelihood of any delays.
A time and motion study is being undertaken by an anaesthetist looking at the theatre pathway that the patient takes from a ward to theatre and back, in order to identify how the system can be improved and made as efficient as possible.
Having a second orthopaedic consultant available has resulted in increased theatre availability and therefore increased efficiency in getting trauma patients to theatre in a timely manner (this is still a trial whilst Philip Yeoman Ward remains closed to elective orthopaedic patients during the winter period. The trial will be evaluated following the reopening of Philip Yeoman after 1st April).
The percentage of patients going to theatre for surgery within the 36-hour target has significantly increased during the closure of Philip Yeoman ward as elective, as indicated in table 4 below:
Table 4:
Reduced length of Length of Stay has been fairly static, this is very much driven by stay of patients who the availability of social services and home first services, which have a broken hip support and assess people in their own homes therefore some (ONGOING) patients may well be therapy and medically well enough for
121 discharge, however social factors extend length of stay. Reduced Pressure ulcers are a recognised complication of any surgical complications post – procedure, and patients who are having hip surgery are at surgery particular risk due to their lack of mobility created by the injury. In (ONGOING) addition, the demographic of hip fracture patients tend to be older and frailer.
From April 2018 to date there have been five category 2 or 3 pressure sores on the trauma wards. Two category 2 pressure ulcers were investigated by tissue viability specialist nurses and felt to be unavoidable meaning that all care was carried out employing full policy and procedures. However, one category 3 pressure ulcer and one category 2 were found to be avoidable when they were investigated. This compares to 2017/18 figures of One unavoidable and four avoidable pressure ulcers, and therefore that has been an improvement in practice.
Work across the organisation continues in the endeavour of reducing this number further. Reduced mortality rate (ONGOING)
Table 5: RUH hip fracture performance against national figures
Table 5 has been adapted from data from the National Hip Fracture Database; it above shows hip fracture data for RUH against national statistics April 2017-March 2019. In relation to the national average, RUH have an above average aged and comorbid population, and therefore when these factors are considered, the 30-day mortality is reduced further. If this is compared to the rest of the country, and taking into account the general demographic of the RUH population, RUH is performing well in terms of maintaining patient safety for this group. Whilst we have successfully achieved against 3 of the 6 standards that we set ourselves. We recognise that our journey for improvement continues, therefore we acknowledge partial achievement for this quality priority
123 How we will continue to work with this priority
The work to improve getting hip fracture patients to theatre within 36hours remains a priority within the department. The changes in practice below will be reviewed and lessons learned actioned in order to take the priority forward and improve the patient pathway
The period during which elective orthopaedic activity has ceased, allowing a second on-call orthopaedic consultant and senior anaesthetic consultant to be available more often, has decreased time to theatre for hip fracture patients.
Anaesthetic approaches are being reviewed between general anaesthetics and spinal anaesthetics may optimise theatre time for this patient group – this will be audited. Incidence where there is a delay to theatre are being DATIX incident reported in order to further identify trends.
Partially Achieved
Priority 4: We will listen to patients and carers and use their feedback to improve Services We will actively collect, use and share patient and carer experience feedback to improve services, quality of care and patient, family and carer experience.
Why it is important:
Using patient and carer experience feedback will: • Develop a culture of continuous learning • Improve patient and carer experience • Improve services to meet the needs of patients and their carers.
What we said we What we did would do Complete a ‘1-year For this review and update to the Board of Directors we identified on’ review of the achievements against the strategy ambitions: Patient and Carer There was a launch on the RUH intranet pages of guidelines Experience Strategy and tools to support staff through the process of collecting and 2017-2020 and plan using patient experience feedback in May 2017. for year 2 of the We increased our support of services developing bespoke strategy and present activities to gather patient and carer experience data. The to the Board of Patient Experience Team had supported 53 projects at the Directors in time of the 1-year on review. September 2018 There was a successful completion and launch of a useful Ward Dashboard for staff to access appropriate, timely information in autumn 2018. Develop the RUH The milestone for quarter 2 of this year was that Patient and Carer electronic data entry Experience questionnaires would be on the RUH website so patients system - eQuest to and carers would have the ability to feedback their experiences enable feedback to electronically. Unfortunately, due to technical problems with e-Quest be collected this was delayed and added to the risk register. Installation of eQuest and recorded on the RUH website to enable patient experience feedback through
124 electronically the website on track to be complete in March 2019. through the Trust website. Support teams and This milestone has been met and since the launch of the Patient and individual staff to Carer Experience Strategy the Patient Experience Team has collect and analyse supported 79 projects across 55 departments and wards (as of patient and carer 25/02/2019). Further information on the projects is included in experience as part quarterly patient experience reports to the Board of Directors of service review (available on the Trust website) and service improvement Formats to collect feedback from patients and their carers include projects. questionnaires, focus groups, shadowing patients and telephone interviews.
The reasons for collecting feedback have been for continuous improvement, Flow (improving patient flow), QSIR projects (Quality and Service Improvement and Redesign), new services reviews, environment reviews, etc.
Below are some examples of where The Patient Experience Team have supported the collection of patient and carer experience feedback with subsequent improvements :
Community Warfarin questionnaire Increased awareness of patient choice to attend a range of clinic venues; making the testing process far more convenient for them.
Appointment Reminder Service electronic survey Patient feedback influenced decision making during the procurement of a new text reminder service.
Neonatal Intensive Care Unit patient story Overnight beds are now provided for parents to stay beside their baby when the NICU accommodation is full and training has been implemented for all staff on how to support mums to breastfeed their babies.
Patient shadowing on Gastroenterology Improvements made to written patient information provided prior to procedure and an upgrade of the patient waiting environment.
Identify learning During 2018-19 have developed feedback reports and information to from patient communicate on a daily (e.g. Friends and Family Test (FFT) experience responses for wards doing Bath Improvement System), weekly (e.g. feedback and complaints updates), monthly (e.g. Patient Advice and Liaison share the results, Services (PALS) and FFT reports) and quarterly (e.g. Quarterly analysis and Patient Experience Divisional Reports) basis. learning from this feedback across the The ward dashboard was launched in September 2018 and gives Trust and the wider staff access to information about patient experience in their community. ward/outpatient area. Feedback from patients/families is collected via the FFT and contacts with the PALS and complaints.
125 Training and embedding on the use of the ward dashboard is ongoing. Measures: Overall year on year We are continuing work with this priority as a Quality Account for improvement in 2019-2020 - by the end of this financial year we will have more national patient understanding of the impact of our work on the results of the national experience survey patient experience survey. results
Increase in service The RUH Patient and Carer Experience Quarterly Reports detail improvements made learning and service improvements as a result of complaints. We as a result of also detail learning from patient stories that are presented to the complaints. This Board of Directors on a monthly basis. information will be included in our quarterly patient experience reports.
Increase in the Since the launch of the Patient and Carer Experience Strategy in May number of services 2017 the Patient Experience Team has supported 79 projects across that have proactively 55 departments and wards to proactively collect and understand collected and used patient and their family and carer experience. patient feedback to improve patient, family and carer experience.
How we will continue to work with this priority
This work will continue as a Quality Account for 2019-20. The milestones identified for 2019- 20 are detailed in Quality Priority 3 below.
Achieved
126 2.17 Priorities for Improvement 2019/2020 – Looking forward to this year
Table 6:
Priorities for Priority 1: Priority 2: Priority 3: Priority 4: Improvement looking Continuity of Development of Improving Improvement forward 2019-20 and Carer Frailty Patient and in early the relationship with Assessment Unit Carer recognition of the True North Goal Experience deteriorating patients Patient Safety Patient Experience Clinical Effectiveness True North Goal Recognised as a listening organisation; patient centred and compassionate Be an outstanding place to work where staff can flourish Quality improvement and innovation each and every day Work together with our partners to strengthen our community Be a sustainable organisation that is fit for the future
Priority 1: Continuity of carer model to personalise services. Why is it important? Quality services for pregnant women need to be personalised as each pregnancy and family are different. Child birth is a life-changing event with experiences that can shape the lives of mothers and their babies. Continuity of carer models will enable maternity services to support this. The model will ensure that care is centred around the woman and her baby so she can access support and information to meet their individual needs. Women will build strong trusting relationships with midwives and other professionals which will improve the safety and quality of their care. What we will do in 2019-2020. 20% of pregnant women will be booked onto a pathway that provides continuity of carer. Create two pilots at two different birthing centres (Frome and Trowbridge). Create a working group to include members from the birthing centres and the acute unit, to scope how we can work across more areas to provide continuity. How will we know we are making a difference: Maternal satisfaction will increase as they will be attended by a midwife that they know. This will result in positive patient feedback/experience about our service. We will be able to evidence safer care. o Women are 7 times more likely to know the midwife at birth o 16% less likely to lose their baby o 15% less likely to have regional analgesia
127 o 24% less likely to experience pre-term birth o 16% less likely to have an episiotomy* Women in these pilot areas should have a midwife, who is part of a small team of 4 to 8 midwives, based in the community who knows the women and family, and can provide continuity throughout the pregnancy, birth and postnatally. Staff sickness rates should reduce as continuity of carer models encourage more flexible working patterns.
*Sandall J, Soltani H, Gates S, Shennan A, Devane D. 28 April 2016. Midwife-led continuity models of care compared with other models of care for women during pregnancy, birth and early parenting. www.cochrane.org/CD004667/PREG_midwife-led-continuity-models-care-compared-other-models-care- women-during-pregnancy-birth-and-early
Priority 2: Development of Frailty Assessment Unit Why is it important? This development will continue to improve the service provision for the frail elderly people. It builds upon the previous work to develop the front door Frailty assessment in the Emergency Department and the introduction on the Frailty Flying Squad. Assessment and Comprehensive Evaluation Older Person’s Unit (ACE OPU) is part of the “front door” of the RUH; it is not a general OPU ward. It is a 27 bedded short stay ward for frail older patients, medically admitted from the Emergency Department or the Medical Admissions Unit who have an expected medical length of stay of less than 4 days. It provides daily senior Geriatrician review and rapid multidisciplinary assessment coupled with a five day community supported multidisciplinary team (MDT) meeting. This model will ensure that patients are seen in a timely manner by the correct clinical team, leading to a more holistic patient experience. The aim is to discharge between 6-8 patients per day. The proposal is that all frail patients are admitted directly to ACE OPU. A recognised clinical frailty score (Rockwood frailty score, a measurement of fitness and frailty) would determine the frailty of the patient and then whether the patient were admitted to ACE OPU or Medical Admissions Unit. What we will do in 2019-2020: Define the frailty pathway to ensure that all appropriate patients are admitted directly to ACE OPU Provide a consistent Frailty Flying Service from 08:00 – 20:00 Increase the number of patients that have a completed Rockwood score and if the score is five and above for the clinical assessment, risk assessment, care planning and ongoing referral to be completed. Decrease length of stay for patients with a Rockwood score of five or above How will we know we are making a difference: Increased number of patients having a Frailty Score to be completed within 30mins of arrival in the Emergency Department Increased numbers of correct patients being directly admitted to ACE OPU Reduce length for patients managed through this pathway and re-admissions within 30 days The discharge pathway streamlined. Increase in discharges from ACE OPU within 72 hours
128 Priority 3: Improving Patient and Carer Experience Why is it important? The experience that a patient and family have in the hospital has a lasting impact and is what they remember. Feedback from patients and their families tells us that we don’t consistently listen and act upon their feedback, learn from them and share the learning with each other. This not only impacts on patient experience, but can affect care quality, especially when learning is not embedded. What we will do in 2019-2020: Improve internal communication of patient experience feedback and the subsequent learning and improvements Design and implement a training programme that empowers staff to confidently respond to verbal concerns Establish a governance structure to identify areas of improvement based on patient / carer experience Celebrate and reward staff who are actively improving patient experience How will we know we are making a difference: Increase in the RUH scores of three identified questions in the annual NHS national staff surveys Reduction in the number of PALS cases and formal complaints Increase in the RUH scores of two identified questions in the NHS national inpatient and maternity surveys A central data-base is developed that includes improvements made as a result of patient and carer experience feedback Increase in the number of improvement tickets involving patient experience / feedback and increase number of huddles involving patients Organise a celebration event that highlights improvements based on patient experience and rewards staff involved in improving patient experience
Priority 4: Improvement in early recognition of deteriorating patients Why is it important? Early recognition of any deterioration in a patient’s clinical condition is essential to allow early review and decision making to occur, so that actions can be taken promptly to either prevent further deterioration, escalate care to a higher level, or make decisions that more aggressive intervention is not in the interests of the patient and allow appropriate care and comfort to be maintained.
The RUH has been using the national Early warning score (NEWS) for many years to support identification of deterioration and an updated version NEWS2 was introduced in November 2018 in line with national recommendations. This is, however, still being manually collected by the nursing staff and to ensure reliable information is available for all patients’ electronic tools are required. What we will do in 2019-2020 For 2019/20 we will continue to improve processes to identify both Sepsis and Acute Kidney Injury (AKI), as early as possible, as well as working on early identification of deterioration from any cause. We have joined the Sepsis, AKI and NEWS working groups to form a Deteriorating Patient Working Group from 2019 and aim to improve early decision making and early implementation of appropriate management for any deteriorating patient. To support that we will be implementing electronic recording of vital signs, such as heart rate and blood pressure. This will enable automatic prompts for deterioration in a patient’s condition, facilitating more reliable
129 identification of unwell patients and automatic screening for Sepsis where indicated. By April 2020, acute teams will also be able to view a patient’s vital signs remotely from other areas of the hospital, enabling them to review those patients with high early warning scores proactively. In 2019 we will also appoint a permanent prevention team for Sepsis and Acute Kidney Injury, the SKIP team (Sepsis and Kidney Injury Prevention), who will continue to educate and support staff in all areas of the hospital to identify Sepsis and any decrease in kidney function early, aiming to improve outcomes further. We will develop ‘deteriorating patient champions’ on all wards; to continue awareness at ward level and also support awareness campaigns planned throughout the year. These ‘NEWS UP, WHATS Up” campaigns, in all ward areas will focus on ensuring staff understand the processes for early identification of any deterioration and continue to focus on sepsis screening and accurate recording of urine output. Tea trolley training (a method of taking training to the clinical area, where staff of all disciplines are encouraged to stop what they are doing for 5- 10 minutes, have a refreshment and undertaking some learning), will be used to support the campaigns and the campaigns will also focus on supporting the new electronic system. We will continue to use patient stories in our training and involve patients in our awareness campaigns. We will develop a process for requesting NEWS score from community colleagues when referring patients including community hospitals, South West Ambulance Service (SWAST) and General Practitioners’, to enable rapid assessment of those with high scores on arrival. How will we know we are making a difference: Implementation of electronic recording observations to all areas by April 2020 Deteriorating champions on all wards by December 2019 SKIP Band 7 and Band 6 nurses appointed by May 2019 Delivered two NEWS UP WHATS Up campaigns by December 2019 Sepsis Screening compliance 90% for all eligible patients including children and maternity by March 2020 Deliver antibiotics in an hour from diagnosis for 90% patients with Sepsis by March 2020 90% patients have vital signs monitored at appropriate time intervals by March 2020 Discharge NEWS score and scale recorded in 80% discharge summaries by December 2019 80% patients referred from primary /community care with have NEWS score on referral by March 2020 5% reduction in incidence of inpatient acquired AKI by March 2020 5% reduction in mortality of Suspicion of Sepsis coded conditions by March 2020
130 2.2 Statement of assurance from the Board of Directors
Mandatory Statement 1 1. During 2018/19 the Royal United Hospitals Bath NHS Foundation Trust provided and/or subcontracted eight relevant health services across three clinical divisions; Medicine, Surgery and Women & Children’s.
1.1. The Royal United Hospitals Bath NHS Foundation Trust has reviewed all the data available to them on the quality of care in all eight relevant health services.
1.2. The income generated by the relevant health services in 2018/19 represents 100% of the total income generated from the provision of relevant health services by the Royal United Hospitals Bath NHS Foundation Trust income for 2018/19.
Mandatory Statement 2 During 2018/19, 48 national clinical audits and 5 national confidential enquiries covered relevant health services that the Royal United Hospitals Bath NHS Foundation Trust provides.
During that period the Royal United Hospitals Bath NHS Foundation Trust participated in 98% of national clinical audits and 100% of national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that the Royal United Hospitals Bath NHS Foundation Trust participated in, and for which data collection was completed during 2018/19, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.
Clinical Audit / National Confidential % cases Participation? Enquiries submitted NCEPOD Child Health Clinical Outcome Review Programme: Cancer in Children, Teens and Young Adults Only eligible for organisational data Yes 100% collection part of the study (not participating in patient data collection) Medical and Surgical Clinical Outcome Preview Yes 100% Programme: Perioperative Diabetes Medical and Surgical Clinical Outcome Review Yes 100% Programme: Pulmonary embolism Medical and Surgical Clinical Outcome Preview Yes 100% (ongoing) Programme: Acute Bowel Obstruction Medical and Surgical Clinical Outcome Review Programme: Long-Term Ventilation Only Yes 100% eligible for organisational data collection part of the study (not participating in patient data collection) Acute
131 Clinical Audit / National Confidential % cases Participation? Enquiries submitted Case Mix Programme (CMP) Yes 100% Feverish Children (care in emergency Yes 100% departments) Major Trauma Audit Yes 73-81% National Audit of Intermediate Care (NAIC) N/A N/A National Emergency Laparotomy Audit Yes 96% (Q3) Vital signs in Adults (care in emergency Yes 100% departments) VTE risk in lower limb immobilisation (care in Yes 100% emergency departments) Blood and Transplant Mandatory Surveillance of Bloodstreams Yes 100% Infections and Clostridium Difficile Infection National Comparative Audit of Blood Transfusion programme: Use of Fresh Frozen Yes 100% Plasma and Cryoprecipitate in Neonates and Children National Comparative Audit of Blood Transfusion programme: Management of Yes 100% Massive Haemorrhage Serious Hazards of Transfusion (SHOT): UK Yes 100% National Haemovigilance Cancer National Bowel Cancer Audit (NBOCA) Yes 84% (2017/18) National Lung Cancer Audit (NLCA) Yes 100% National Oesophago-gastric Cancer (NAOGC) 61-70% (2018 Yes report) Heart Adult Cardiac Surgery N/A N/A Cardiac Rhythm Management Yes 100% Myocardial Ischaemia National Audit Project Yes 100% (MINAP) National Audit of Cardiac Rehabilitation Yes 100% National Audit of Percutaneous Coronary Yes 100% Interventions (PCI) National Cardiac Arrest Audit Yes 100% National Congenital Heart Disease (CHD) N/A N/A National Heart Failure Audit Yes 100% Long term conditions Inflammatory Bowel Disease programme / IBD Database still not registry No live, no cases submitted National Asthma and COPD Audit Programme Yes 100% National Clinical Audit for Rheumatoid and Yes 100% Early Inflammatory Arthritis (NEIAA) National Diabetes Audit - Adults Yes 100%
132 Clinical Audit / National Confidential % cases Participation? Enquiries submitted National Paediatric Diabetes Audit (NPDA) Yes 100% Mental Health Mental Health Clinical Outcome Review N/A N/A Programme National Audit of Anxiety and Depression N/A N/A National Audit of Psychosis N/A N/A Prescribing Observatory for Mental Health N/A N/A (POMH-UK) Older People Falls and Fragility Fracture Audit Programme Yes 100% (FFFAP) National Audit of Breast Cancer in Older Yes 100% People National Audit of Dementia Yes 100% Sentinel Stroke National Audit Programme Yes 100% (SSNAP) Other Adult Community Acquired Pneumonia Yes 100% Elective Surgery (National PROMs Yes 100% Programme) Learning Disability Mortality Review Yes 100% Programme (LeDeR) National Audit of Care at the End of Life Yes 100% National Audit of Intermediate Care N/A N/A National Audit of Pulmonary Hypertension Yes 100% National Bariatric Surgery Registry (NBSR) N/A N/A National Audit of Specialist Rehabilitation for Patients with Complex Needs Following Major N/A N/A Injury (NCASRI) National Joint Registry Yes 100% National Mortality and Case Record Review N/A N/A Programme National Ophthalmology Audit Yes 100% National Vascular Registry N/A N/A Neurosurgical National Audit Programme N/A N/A Non-Invasive Ventilation - Adults Yes 100% Reducing the impact of serious infections Yes 100% (Antimicrobial Resistance and Sepsis) Seven Day Hospital Services Yes 100% Surgical Site Infection Surveillance Service Yes 100% Urology BAUS Urology Audit - Cystectomy N/A N/A BAUS Urology Audit – Female Stress Urinary N/A N/A Incontinence (SUI) BAUS Urology Audit – Nephrectomy Yes 100%
133 Clinical Audit / National Confidential % cases Participation? Enquiries submitted BAUS Urology Audit – Percutaneous Yes 100% Nephrolithotomy (PCNL) BAUS Urology Audit – Radical Prostatectomy Yes 100% National Prostate Cancer Audit Yes 100% Women’s & Children’s Health Maternal, Newborn and Infant Clinical Yes 100% Outcome Review Programme National Audit of Seizures and Epilepsies in Yes 100% Children and Young People National Maternity and Perinatal Audit (NMPA) Yes 100% National Neonatal Audit Programme Yes 100% Paediatric Intensive Care (PICANet) N/A N/A UK Cystic Fibrosis Registry Yes 100%
The reports of 28 national clinical audits were reviewed by the provider in 2018/19 and the Royal United Hospitals Bath NHS Foundation Trust intends to undertake the following actions to improve the quality of healthcare provided.
Sentinel Stroke National Audit Programme (SSNAP). The audit monitors performance across ten domains which include efficiencies with treatment, therapy input and discharge processes. Each of the domains receives an overall score, and is categorised into a level (A-E) with A indicating high performance and E indicating poor performance. The audit findings from July to September 2018 showed a reduction in compliance with the audit standards. The total indicator level has gradually decreased from an A in 2017 to a C. This is due to a drop in banding in three domains – Occupational Therapy, Speech and Language Therapy (now an E) and Multidisciplinary Team (MDT) Working. It is expected that this is due to staffing issues pertaining to absences which have not been covered. The Speech and Language Therapist for stroke has been required to cover an empty post in another area of the Trust which has been vacant for some time. There has also been a significant reduction in weekend therapy cover which has led to a drop in compliance with the therapy based standards. It is anticipated that seven day working across therapies and the management of beds by the Stroke Team will increase the banding in these areas. Three stroke Medical Nurse Practitioners were appointed in early 2018 to support front door stroke work.
National Hip Fracture Database. The report showed that the Trust was below the national average for hip fractures which were sustained as an inpatient. Performance was declining during the period. During and since the audit there has been a widespread quality improvement drive surrounding the prevention of inpatient falls. A falls simulation project has been undertaken to educate and train staff on falls prevention and the actions to take if a patient sustains a fall. From November 2018 a new standard for lying and standing BP has been introduced (as recommended by the Royal College of Physicians) – a new section has been added to the NEWS 2 charts. The Trust’s falls intranet page has been updated to provide staff with a resource and a falls pathway relaunch event increased awareness of the new documentation and changes to the falls pathway.
134 National Neonatal Audit Programme. The report showed that the Trust performed better than the national average in 6 standards and lower than the national average in 3 standards. These 3 standards relate to the temperature of babies born <32 weeks admitted to the unit, documented consultation of parents with a senior member of the team and screening time for ROP. To promote normal temperature on admission for very preterm babies, a new Trust Humidity Guideline has been written regarding the transfer of babies from delivery suite to NICU. A new data clerk has been appointed which it is anticipated will result in more complete and better documentation on the BadgerNet database. An additional ophthalmologist has been brought in to perform Retinopathy of Prematurity (ROP) screening during periods where the initial ophthalmologist is absent. With regard to ROP screening, the Trust was below the national average but the report for 2018/19 Quarter 3 shows that the Trust is currently higher than the national average.
In 2017/18 the Trust participated in the Royal College of Emergency Medicine (RCEM) audit – Fractured Neck of Femur. The Trust performed better than the national average in 5 standards and worse than the national average in 3 standards. These 3 standards relate to the timely administration of analgesia, time to X-ray and the 4 hour arrival-to- admission target. Posters have been produced and displayed in the relevant clinical areas which emphasize timely prescription and administration of analgesia, timely x-rays, reviews and referrals, femoral nerve block and IV fluids and drug charts. Education and training involving the Abbey Pain Scale and an overview of treatment pathway has been provided to all staff. Reminders have been added to FirstNet to guide staff during treatment. A new ‘Neck of Femur’ meeting group has been formed to look at fast-tracking patients, time to wards and patients with a confirmed fracture diagnosed admitted to the Trust from elsewhere. The foundation year two programme now includes teaching around falls and these fractures sustained on wards at the Trust and how to manage and refer them.
In 2017/18 the Trust participated in the RCEM audit – Procedural Sedation. The Trust performed equally to or better than the national average in 10 standards and worse than the national average in 3 standards. These 3 standards relate to the use of LocSSIPs / NatSSIPs checklists, documented assessment of suitability of discharge and the provision of written advice on discharge. Since the audit and prior to the publication of the results a separate checkbox has been added to the sedation proforma. This is part of a larger project involving the use of these checklists in the Emergency Department for all significant or invasive procedures and is accompanied by a multidisciplinary education programme.
Falls and Fragility Fracture Audit Programme (FFFAP): Fracture Liaison Service (FLS) database. The Trust is now 6th out of 59 participating Fracture Liaison Services for patient identification. Despite our staffing levels and the hours that have been allocated to updating and monitoring the database, the Trust’s patient identification has been higher than that the national average since early 2017. A FLS database tool has been developed and implemented by the Trust’s Fracture Liaison Service; the tool has significantly reduced the time that is required to successfully participate in the programme. The tool keeps a comprehensive record of patients that have been recruited into the database and provides the function of automatically producing follow-up letters which are distributed to patients. Currently, the Trust only completes 4 month follow-ups
135 for patients within the Somerset Clinical Commissioning Group (CCG) due to funding. This explains why the standards relating to 4 month follow-ups are areas that the Trust does not come across well in. It is planned that a Rheumatology Specialist Registrar (SpR) will review 12 month adherence between Bath and North East Somerset (BANES) and Somerset patients. It is hoped that this will indicate the benefit that the extra 4 month follow-ups of Somerset patients has on adherence and therefore provide the Trust with data to approach the other CCG’s to make the case for them to fund 4 month follow-ups.
The results of the 2017/18 National Comparative Audit of Blood Transfusion Programme: Transfusion Associated Circulatory Overload were published in the 2018/19 period. The audit highlighted a number of areas for improvement. In response to the recommendations, it is planned that an electronic powerplan for the documentation of indication, risk assessments and for single unit red cell transfusions will be introduced. Actions/steps to take to reduce risk factors are included in the paper care plan and are to be added to the powerplan to aid staff. Medical mandatory training has been updated to improve staff awareness and knowledge. An audit will be conducted in the near future to determine if the actions have been successfully implemented and if any changes are being adhered to.
The reports of 90 local clinical audits were reviewed by the provider in 2018/19 and the Royal United Hospitals Bath NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided.
RUH Audit of Antiphospholipid Testing. The audit showed that only 76% of appropriate laboratory comments are added to positive samples and only 72% of all patients undergoing initial assessment for antiphospholipid syndrome (APS) had full laboratory testing. In response to these findings, the Trust aims to establish an electronic requesting pathway for antiphospholipid antibody testing with appropriate input/support from the laboratory Information Management and Technology (IM&T) team. Whilst clinical criteria were not reviewed in the audit, laboratory testing was suboptimal against recommended guidelines in 28% of patients during the audit period. The aim is to establish a single electronic order set, available to all clinical areas, to incorporate appropriate clinical information, optimise the testing pathway, eliminate duplicate requesting and hence improve the value and efficiency of laboratory investigation of APS. Such an approach will allow integrated reporting, with risk stratification of laboratory data, improving the quality of reporting to clinicians.
Fine Bore Nasogastric Feeding Tube for Adults Care Plan audit. There were areas of the audit that were graded as amber and red. These standards related to the documentation within the care plan. In response, there has been continued emphasis on documentation during the theoretical component of the training session for registered nursing staff. It has been advised that out-of-hours X-rays to confirm the position of the nasogastric tube should not be performed unless urgently clinically required. This will reduce the risk of an X-ray not being reviewed by appropriately qualified medical staff. This will be added to the Trust’s Nasogastric feeding policy
Audit of Minor Operating Procedures, waiting times and booking processes. The audit showed that the Dermatology department was struggling to accommodate urgent
136 procedures (within 31 days) with the current system that is in place and the current staffing levels. Decisions to Treat (DTT) times are now logged to help prioritise bookings. All patients with a suspected cancer should be listed for a procedure within 2 weeks (and circled as urgent on the clinical outcome form). The ‘soon’ category has been adjusted from 6 weeks to 10 weeks, and ‘non-urgent’ will remain as 18 weeks. The relevant breach date, either Referral to Treatment (RTT) or cancer will be documented on the top right hand corner of the yellow Minor Operating Procedures (MOP) form once it has been received by reception – this will help reception staff who book the procedure to schedule MOPs procedures within the desired time frame. A yellow form, outcome form and histology form will be completed for every patient referred for a MOPs procedure, even if the plan is for the referring clinician to carry out the procedure themselves. This will provide reception and clinical staff with more information to help decide on the appropriateness of re-scheduling procedures if required to accommodate an urgent request and to ensure the safe and smooth running off ‘pooled’ theatre lists.
Mandatory Statement 3
The NHS has a clear mandate from government that it should be committed to research and the use of research evidence in its clinical activities. Patients benefit from access to clinical trials including cutting edge treatments and the NHS benefits from new medicines, technologies and processes. Consequently, the RUH aims to provide as many patients as possible with the opportunity to participate in research trials and have access to treatments that might not otherwise have been available to them.
The number of patients receiving relevant health services provided or sub-contracted by the Royal United Hospitals Bath NHS Foundation Trust in 2018/19 that were recruited during that period to participate in research approved by a research ethics committee was 2456, which represents a 12.5% increase compared to figures from 2017/18.
Currently, there are just over 300 trials open with patients either receiving treatment or in follow-up, with approximately a further 30 trials currently in set-up.
The Trust continues to work closely with industry partners to deliver a wide variety of studies in numerous clinical specialties and provide access to treatments not currently available. Moreover, these commercial partnerships provide an external source of funding.
The RUH continues to expand its portfolio of research which is initiated and run by our own research staff, encompassing consultants, research nurses and allied health professionals, a number of whom hold academic Professor and lectureship positions in a variety of clinical areas. The RUH continues to work collaboratively with surrounding universities including the Universities of Bath, Bristol and The West of England. In 2018/19, the Trust held its first RUH Research Showcasing Event which was held in collaboration with the University of Bath and attracted over 100 attendees. It is envisaged that this event and similar future events with other universities will forge new research partnerships moving forward.
137 The following grants were awarded to Trust researchers in 2018/19:
Grant Provider Project Title Lead Applicant Specialty Amount Other awarded information
US Department Optimizing Patient- Dr John Pauling Rheumatology US$1.2 million Collaborative of Defence Reported and Vascular project with 3 Outcome Measures in organisations Systemic Sclerosis- including John Associated Raynaud Hopkins and Phenomenon Pittsburgh University
Scleroderma Development and Dr John Pauling Rheumatology US$12,000 Clinical Trials validation of a novel Consortium patient-derived patient- reported outcome instrument for assessing the activity and impact of Raynaud’s phenomenon in systemic sclerosis
Bath Institute for Grant to fund MSc Dr John Pauling Rheumatology £10,000 Awaiting Rheumatic students to complete and funding Diseases enhance research done outcome by Dr Vicky Flower into vasculopathy in scleroderma
National Assessing the impact of Dr Raj Sengupta Rheumatology £30,000 Ankylosing rehabilitative interventions Association on the natural history of (NASS) ankylosing spondyloarthritis
Gatsby Change of care Dr Emily Ageing 3.2 million This is a joint Foundation perspective from Henderson (Parkinsons) Euros application secondary to primary care with the Netherland/UL C.
National Improving outcomes for Dr Sara-Catrin Anaesthesia £17,479 Institute of frail patients undergoing Cook Academic elective colorectal cancer Anaesthesia surgery
National The Videolaryngoscope Dr Sara-Catrin Anaesthesia £4882 Institute of Airway Database App Cook Academic Project Anaesthesia/AA GBI
National Pre-Clinical Doctoral Sandi Derham Rheumatology £60,534.00 Institute for Fellowship Health
138 Research
Ely Lilly Clinical Phenotypes of Dr William Tillett Rheumatology £108,050.00 Psoriatic Arthritis Patients based in UK Rheumatology Clinics
Versus Arthritis A Sensory Training Professor Pain £100,000 Held at UWE System (STS) for use at Candy McCabe home by people with persistent limb pain.
Novartis Joint working agreement Dr Raj Sengupta Rheumatology £22,701 Pharmaceuticals to audit Ankylosing UK Ltd Spondylitis patients care pathway against NICE Guideline
Mandatory Statement 4
A proportion of the Royal United Hospitals Bath NHS Foundation Trust in 2018/19 was conditional on achieving quality improvement and innovation goals agreed between the Royal United Hospitals Bath NHS Foundation Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of relevant health services, through the Commissioning for Quality and Innovation payment framework. Further details of the agreed goals for 2018/19 and for the following 12 month period are available at www.england.nhs.uk/nhs-standard-contract/cquin/cquin-17-19/
This year, it is anticipated that the Trust will receive £5.7m in CQUIN payments out of a possible £5.8m, which represents 98 percent achievement. In the previous year, 2017/18 the Trust achieved 83 per cent achievement, £4.7m out of a possible £5.6m.
Mandatory Statement 5
The Royal United Hospitals Bath NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is ‘registered’. The Royal United Hospitals Bath NHS Foundation Trust has no conditions attached to its registration.
The Care Quality Commission has not taken any enforcement action against the Royal United Hospitals Bath NHS Foundation Trust during 2018/19.
Mandatory Statement 6 Removed
Mandatory Statement 7
The Royal United Hospitals Bath NHS Foundation Trust has not participated in any special reviews or investigations by the CQC during the reporting period.
139 Mandatory Statement 8
The Royal United Hospitals Bath NHS Foundation Trust submitted records during 2018/19 to the Secondary Uses service for inclusion in the Hospital Episode Statistics, which are included in the latest published data.
The percentage of records in the published data*:
Which included the patient’s valid NHS number was:
99.7% for admitted patient care 99.9% for outpatient care 98.8 % for accident and emergency care
Which included the patient’s valid General Medical Practice Code was:
100% for admitted patient care 100 % for outpatient care 100% for accident and emergency care
*Based on Provisional April 2018 to February 2019 SUS Data at the Month 11 Inclusion Date published by NHS Digital
Mandatory Statement 9
The Royal United Hospitals Bath NHS Foundation Trust Information Governance Assessment Report overall score for 2018/19 was 100% and was graded green (satisfactory).
Mandatory Statement 10
The Royal United Hospitals Bath NHS Foundation Trust was not subject to the Payment by Results clinical coding audit during 2018/19 by the Audit Commission.
Mandatory Statement 11
The Royal United Hospitals Bath NHS Foundation Trust will be taking the following actions to improve data quality: Continue to use and further develop the Data Quality Assurance Framework implemented during 2015/16 as a way of assessing the quality of information reported to the Board. This process assigns a confidence rating to key performance standards based on the outcome and frequency of internal and external data quality audits. Continue to incorporate Data Quality in the Internal Audit Programme, ensuring that the quality of information remains a high priority for the Trust. Continue the work of the Data Quality Steering Group, which meets regularly to oversee data quality within the Trust. The group monitors data quality issues and receives the outcomes of audits and external data quality reports to support resolution of issues and improvement work. The meetings are attended by staff from the information department and staff working in operational roles as well as finance and IM&T to make sure that the Trust maintains high quality and accurate patient information to support patient care.
140 Action any data quality issues raised by Commissioners and other NHS and non- NHS bodies that receive and use the Trust’s data.
Learning from Deaths
Mandatory statement 27.1
During 2018/19 1306 of The Royal United Hospitals Bath NHS Foundation Trust patients died. This comprised the following number of deaths which occurred in each quarter of that reporting period:
327 in the first quarter 288 in the second quarter 352 in the third quarter 339 in the fourth quarter
Mandatory statement 27.2
The process for selecting patient deaths was paused at the beginning of Quarter 1 while being restructured and improved. Consequently we have only been able to report limited data in Quarter 1 and more complete data about this process in Quarter2, Quarter 3 and Quarter 4. Reviews continued for the 2017/18 patients who died in Quarter 4 and this is recorded in 27.7 below.
By 11th February 2019, 385 case record reviews and 52 investigations have been carried out in relation to 979 of the deaths included in item 27.1.
In 8 cases a death was subjected to both a case record review and an investigation. The number of deaths in each quarter for which a case record review or an investigation was carried out was:
21 in the first quarter 169 in the second quarter 170 in the third quarter 24 in the fourth quarter
Mandatory statement 27.3
0 representing 0% of the patient deaths during the reporting period are judged to be more likely than not to have been due to problems in the care provided to the patient. In relation to each quarter, this consisted of:
0 representing 0% for the first quarter 0 representing 0% for the second quarter 0 representing 0% for the third quarter 0 representing 0% for the fourth quarter
These numbers have been estimated using the Royal College of Physicians Structured Judgement Review (SJR) tool which is used to investigate the care of patients whose death triggers on initial review using a screening tool.
141 The Trust also ensures service improvements are identified and implemented following Coroners’ Inquests. When notified of an inquest where a serious incident investigation has not already been carried out this will prompt consideration as to whether one is required; families expressing concerns are directed to the formal complaint process and any feedback provided by families or the Coroner during a hearing are noted and fed back to the relevant teams.
Mandatory statement 27.4
The Trust is still developing and embedding the methodology that will reliably allow us to review all deaths going forwards. The pilot system was reviewed in Q1 2018/19 and the new revised system launched at the beginning of Q2. While we are reporting 0 cases during the reporting period judged to be more likely than not to be due to problems in the care provided to the patient, we did in 49 cases identify problems with care that did not directly contribute to the death, but non the less provided important learning. Examples of areas of learning include:
Delayed recognition of deterioration of patients on medical wards due to acute surgical problems Peri-operative nutrition Record keeping Medicines reconciliation on admission Delay in escalating deterioration in NEWS
We expect to gain greater insights and learning as the work gains momentum.
Mandatory statement 27.5
As part of our Trust Strategy we have identified our Quality True North Goal to achieve “quality improvement and innovation each and every day” as measured by a reduction in avoidable harm and mortality. We are focusing in particular on the recognition of the deteriorating patient and medicines safety. Both of these areas are themes in the reviews.
Mandatory statement 27.6
The Trust will be rolling out electronic observations to support our teams in appropriately utilising the early warning scores and to facilitate early escalation of the deteriorating patient. There is a newly formed deteriorating patient group chaired by the Medical Director. This group will coordinate developments such as the critical care outreach team expanding into 24/7 working, sepsis screening, acute kidney injury and escalation of clinical concerns.
Mandatory statement 27.7
149 case record reviews and 0 investigations completed after 31th March 2018 which related to deaths which took place before the start of the reporting period.
Mandatory statement 27.8
0 representing 0% of the patient deaths before the reporting period are judged to be more likely than not to have been due to problems in the care provided to the patient. This number has been estimated using the Royal College of Physicians Structured Judgement
142 Review (SJR) tool which is used to investigate the care of patients whose death triggers on initial review using a screening tool.
Mandatory statement 27.9
0 representing 0% of the patient deaths during 2017/18 are judged to be more likely than not to have been due to problems in the care provided to the patient. 2.3 Reporting against core indicators
Summary Hospital Level Mortality Indicator (SHMI)
The Royal United Hospitals Bath NHS Foundation Trust considers that this data is as described for the following reasons:
The data is published by NHS Digital using data provided by the Trust. SHMI is reported as a twelve month rolling position, and the reporting periods shown are the latest available from NHS Digital.
The SHMI value is better the lower it is. The banding level helps to show whether mortality is within the “expected” range based on statistical methodology. There are three bandings applied, with a banding of two indicating that the mortality is within the expected range. The Trust has a value of two meaning that mortality levels are not significantly higher or lower than expected.
The Royal United Hospitals Bath NHS Foundation Trust intends to take or has taken the following actions to improve this indicator, and so the quality of its services by:
The Trust scoring against this measure is within the expected range and the latest published figures show an improvement on the previous period. Because of this no specific improvement actions have been identified, however the Trust is committed to continuing to reduce mortality as measured by both SHMI and HSMR (Hospital Standardised Mortality Ratio) indicators. The Trust performance against HSMR is detailed in section three of the Quality Accounts.
Our Clinical Outcomes Group, chaired by the Medical Director, monitors these indicators on a regular basis, and we use the Dr Foster Intelligence System to monitor mortality and clinical effectiveness
143 Patient Reported Outcome Measures (PROMS)
The Royal United Hospitals Bath NHS Foundation Trust considers that this data is as described for the following reasons
The data is published by NHS Digital using data provided by the Trust and patient responses. The Trust give pre-operative questionnaires to all eligible patients and a follow up post-operative questionnaires sent to patients by an external company in line with national guidance.
Information is only available for some measures for the Trust against PROMS measures for the most recent reporting period. This is because a low number of the post-operative questionnaires have been returned to date, due to the time it takes to gather and process responses. Small numbers are not published because it is difficult to make accurate assumptions about improvements in care, and in some cases information has to be excluded to protect patient confidentiality.
The reporting periods shown are the latest available from NHS Digital
The Royal United Hospitals Bath NHS Foundation Trust intends to take or has taken the following actions to improve this indicator, and so the quality of its services by:
Historically the Trust scoring against this measure has been within expected range (above national average) for the majority of areas. Because of this, no specific improvement actions have been identified.
There are three different measures included in PROMS, the EQ VAS, EQ-5D Index and Oxford hip and knee scores. The EQ-5D Index is a combination of five key criteria concerning general health and EQ VAS is the current state of the patients general health marked on a visual analogue scale. The Oxford Hip and Knee scores relate specifically to the patient's condition and therefore are a particular area of focus for the Trust when monitoring PROMS results.
Following on from an NHS England Consultation on PROMS collection of varicose vein and groin hernia procedures ceased on 1st October 2017
144 The Trust will continue to review performance against PROMS measures when more recent data becomes available.
Re-admissions
The Royal United Hospitals Bath NHS Foundation Trust considers that this data is as described for the following reasons:
Published data from NHS Digital for the most recent time periods was not available at the time of reporting, and so in order to provide more up to date information the performance above has been taken from a different source. The data has been taken from Dr Foster Intelligence, a benchmarking tool used by the Trust to monitor patient outcomes using data submitted by the Trust. National comparison figures have also been taken from Dr Foster for 2017/18 based on non-teaching Acute Hospital Trusts.
Due to the time it takes to publish the data we are only able to include figures from April – September 2018 as the latest period.
The Royal United Hospitals Bath NHS Foundation Trust intends to take or has taken the following actions to improve this indicator, and so the quality of its services by:
The children’s readmission rate has seen a small increase in the period April – September compared to the annual rate seen in 2017/18, while the adult rate has remained the same. Re-admission rates published by Dr Foster are reviewed at the Trust’s monthly Clinical Outcomes Group meeting that is chaired by our Medical Director. The paediatric service provides open access as a safety net and therefore would expect to have a percentage of children returning to hospital.
Responsiveness to personal needs of patients
The Royal United Hospitals Bath NHS Foundation Trust considers that this data is as described for the following reasons
The data is published by NHS Digital using patient responses to the National Inpatient Survey. The list of patients was provided by the Trust using the methodology and criteria specified for the survey. In order to protect the confidentiality of responses the survey was administered and analysed by Picker, a Care Quality Commission (CQC) approved external contractor. The inpatient overall score uses the results of a selection of questions from the survey looking more broadly at hospital care.
145 The Royal United Hospitals Bath NHS Foundation Trust intends to take or has taken the following actions to improve this indicator, and so the quality of its services by:
The results for the National Inpatient Survey 2017 were presented to the Board of Directors in July 2018. The CQC compared the Trust responses to the survey questions against all other acute Trusts and whether the RUH was ‘better’, ‘worse’ or ‘about the same’. In 2017, the Trust scored better than average on two questions ‘Did you get enough help from staff to eat your meals?’ (8.4/10) and ‘After the operation or procedure, did a member of staff explain how the operation or procedure had gone in a way you could understand?’ (8.5/10). There were no questions where the Trust was in the ‘worse’ performing category.
There was one question where the Trust score showed a ‘statistically significant decrease’ which related to patients bringing their own medication in to hospital and being able to take it when they needed to. A pilot project for insulin dependent diabetics being able to take their insulin as they would normally at home has been successful and is being rolled out across the wards.
Staff recommending the Trust to family and friends
The Royal United Hospitals Bath NHS Foundation Trust considers that this data is as described for the following reasons
The data shown is taken from the NHS Staff Survey. The survey is run and analysed by an external company and so this cannot be calculated internally. This is done in line with national guidance. For the past 4 years all staff members were given the opportunity to complete a staff survey to make sure opinions were captured from as many people as possible.
The Royal United Hospitals Bath NHS Foundation Trust intends to take or has taken the following actions to improve this indicator, and so the quality of its services by:
The Trust scored above the national average for acute trusts for this measure, and the proportion of staff who would recommend the Trust for treatment to friends and family has remained improved on last year’s results. The Trust has commenced a programme called Improving Together, a long-term improvement program unlike anything we have ever committed to before. It will help us deliver our vision to provide the highest quality of care. It will help us to live our values. It will see us working together on a few shared goals, with every improvement effort we make bringing us closer to reaching them
146 Venus thromboembolism (VTE)
The Royal United Hospitals Bath NHS Foundation Trust considers that this data is as described for the following reasons:
The data shown is published by NHS Digital using data provided by the Trust. The figures published are consistent with local calculations of the information that has been submitted.
Performance is published as quarterly totals. At the time of reporting only comparative data to the end of quarter three of 2018/19 has been published.
The Royal United Hospitals Bath NHS Foundation Trust intends to take or has taken the following actions to improve this indicator, and so the quality of its services by:
Following implementation of the electronic prescribing medication administration system (ePMA) in November 2017, the risk assessment for VTE became electronic and this has resulted in the data being more reliable and has consistently shown a compliance of over 90%. Clostridium difficile (C. difficile)
The Royal United Hospitals Bath NHS Foundation Trust considers that this data is as described for the following reasons
The performance shown for the current reporting period (April 2018 to March 2018) has been calculated internally by the Trust using data submitted nationally as published data was not available at the time of reporting. The comparative data for 2017/18 is published by NHS Digital.
During 2018/19 the Trust has reported a total of 32 cases of Clostridium difficile infection however it has been agreed by the Commissioners that no lapses in care occurred in 5 of the cases and are therefore not counted against the year-end total, resulting in 27 actual cases. A further 4 cases are awaiting appeal decisions, the result of which are not known at the time of writing this report.
The Royal United Hospitals Bath NHS Foundation Trust intends to take or has taken the following actions to improve performance, and so the quality of its services by:
147 Completion of an improvement action plan following a visit from NHS Improvement in January 2018. A new action plan has been commenced to include areas where lapses of care have been documented following analysis of cases during 2018/19. Actions include improved stool sampling and documentation, support and education for ward teams when a case occurs and a focus on cleaning across the Trust.
Incidents
The Royal United Hospitals Bath NHS Foundation Trust considers that this data is as described for the following reasons:
The performance shown is for the latest and most recent reporting periods published by NHS Digital.
Incident reporting remains consistent for the patient population using Trust services. The increase in the most recent data is a reflection of the winter pressures, an increasing population and longer life expectancy. Further to this are staffing concerns which reflect a national picture of infrastructure where recruitment to full establishment is a challenge. Patient falls are among the top three reported category of incidents. Falls reporting is driven by the falls steering group highlighting to staff the need to report these type of incidents to assist in the development, implementation and monitoring the impact of a falls prevention work plan. The level of severe harm has slightly increased compared to the same time period of the previous year. Sharing learning across the Trust and reviewing severe harm incidents at multidisciplinary meetings has contributed to a pro-active culture with a reduction in severe harm events. However, winter pressures have an impact on incidents being higher than those over the summer months.
The Royal United Hospitals Bath NHS Foundation Trust intends to take or has taken the following actions to improve this indicator, and so the quality of its services by:
Training in reporting and management of patient safety incidents has been offered to staff in ward areas with support from the clinical risk team. Root cause analysis training has commenced on a monthly basis which is offered to all clinical and non-clinical managers across the Trust. Implementation of a new approach to falls investigations using a work plan to identify new learning will provide focus on prevention and reducing harm from falls. Recruitment of Divisional Patient Safety leads has contributed to increased awareness of the need to report. Patient safety leads across the Trust actively support staff involved in incidents, advise on investigating incidents including serious incidents and promote sharing the learning from patient safety investigations through local specialist governance processes. The Clinical Risk team continues to work with Divisional leads and the Quality Improvement Team to support a pro-active approach to patient safety ensuring processes are streamlined to produces meaningful outcomes that can be shared across the Trust through internal networks and governance processes.
148 Part 3 Other Information
149 Part 3 Other information
3.1 Local Quality Indicators – clinical effectiveness; patient safety; and patient experience
This section of our Quality Accounts provides an overview of the quality of care we provided in 2018 /2019. The information shows our performance against mandated indicators as set out in the guidance from NHS Improvement and also against a number of indicators selected by the Board of Directors in consultation with our Commissioners.
Three indicators have been selected from each of the domains of patient safety, clinical effectiveness and patient experience. Where possible, we have included our previous year’s performance and how we benchmark against the national average.
These indicators have been selected from the Trust’s Integrated Balanced Scorecard and fit with the domains of caring, effective, safe, responsive and well led. They also link with areas that we have identified in our Quality Account priorities, CQUIN targets and patient safety priorities. We believe that our performance against these indicators demonstrates that we are providing high quality patient centred care which will continue to be monitored over the coming year.
Patient Safety
The patient safety indicators are:
1. Falls 2. Infections 3. Pressure Ulcers
Falls
Falls performance is reported in more detail in section 2.14
150 Infections
Reducing avoidable healthcare associated infections is an important factor for improving patient safety.
The Infection Prevention and Control Team have been working collaboratively with both our clinical partners within the Clinical Commissioning Groups and other healthcare providers to drive a whole health economy approach to reducing infections.
Mandatory surveillance of methicillin- resistant Staphylococcus aureus (MRSA), Gram negative bloodstream infections and Clostridium difficile has continued during 2018/19. Learning from these incidents has been used to improve practice and identify where there are gaps in knowledge.
Clostridium difficile performance is reported in more detail in section 2.14
During 2018/19 there were two Trust attribute MRSA bloodstream infections. Post infection reviews and root cause analysis investigations were carried out for both cases. One case was deemed to be unavoidable; the source of infection was a chest infection. The other was probably avoidable; the patient was at high risk developing a blood stream infection due to previous colonisation with MRSA and lifestyle. The source of infection was a central venous access line. Learning has been identified in both cases and the action plans have been monitored through the divisional governance structure.
Mandatory surveillance is carried out for three types of Gram negative blood stream infections: E coli, Klebsiella spp and Pseudomonas aeruginosa. All cases are reported through the Public Health England data capture tool. There is a government ambition to reduce Gram negative blood stream infections by 50% by 2021. E coli form the largest number of these infections therefore the focus nationally has been on reducing healthcare associated cases by 50%, starting with a 10% reduction target for each of the first two years. Healthcare associated infections can be acquired from any healthcare intervention and the target is shared with the wider health community.
151 During 2018/19 the number of healthcare associated E coli blood stream infections was 61 which is a reduction of 13% on last year.
Pressure Ulcers
2018/19 2017/18 2016/17 2018/19 2018/19 2018/19 Did we Have we Total Average Total Average Trust Total Average achieve in improved per per local per month 2018-19 on 2017- month month target against our 18? local target? Category Category 12 8 0.6 15 1 34 3 two two Medical 8 5 0.4 6 0.5 15 1 device related Category 0 2 0.1 1 0 3 0 three Category 0 0 0 0 0 1 0 four
The ambition for 2018/19 is a 20% reduction of avoidable category 2 pressure ulcers, 25% reduction of avoidable Medical Device Related pressure ulcers and the elimination of all avoidable category 3 and 4 pressure ulcers.
The ambition remains to have a zero tolerance for all pressure ulcers.
There have been 8 avoidable category 2 pressure ulcers in 2018-19 which is a 33% decrease from 2017-18.
There have been 5 avoidable medical device related pressure ulcers in 2018-19 which is a 37% decrease from 2017-18.
There have been 2 avoidable category 3 pressure ulcers in 2018-19 which is a 50% increase from 2017-18
There have been 0 avoidable category 4 pressure ulcers in 2018-19. Following full RCA investigation of a patient with a category 3 and a patient with a category 4 pressure ulcer, all interventions were found to be correct and timely and therefore deemed unavoidable as per International guidance (EPUAP, NPUAP, PPPIA 2014)
The Royal United Hospitals NHS Foundation Trust has a clear pathway for pressure ulcer prevention and regular awareness campaigns to keep pressure ulcer prevention at the forefront of providing quality care.
Where the Trust saw an increase in the number of pressure ulcers around September and October in line with other Trusts in England, further improvement plans were put in place and monitored by the Senior Nursing team and the Tissue Viability Steering group. These actions saw an immediate effect with a decrease in avoidable harms which has so far been sustained.
All hospital acquired pressure ulcers are investigated to identify any themes and potential learning. These are then used to drive improvement work at local and Trust level.
152 We are confident that our pressure ulcer data is accurate. Pressure ulcers are recorded on our electronic patient record and our DATIX incident reporting system. These are then checked and confirmed by our Tissue Viability team. An annual prevalence is carried out to provide assurance that the incidence data we are capturing is accurate and figures were improving.
In 2019 the NHS Improvement national guidance for measurement and data collection will slightly change the way we report to include avoidable/unavoidable pressure ulcers; we currently report avoidable pressure ulcers for quality accounts. This will mean the figures will appear to be higher next year but the Trust will continue to ensure the prevention of all pressure ulcers remains a priority.
Clinical Effectiveness
The clinical effectiveness indicators are:
1. Sepsis 2. Cancer Access Targets 3. Summary Hospital Level Mortality Indicator (SHMI) 4. Hospital Standardised Mortality Ratios (HMSR)
Sepsis
Sepsis is a national priority being driven by NHS England and although there is not a Sepsis CQUIN for 2019/20 it continues to be priority nationally and forms part of the CCG contract.
The data includes adults, paediatrics, direct admissions and inpatients. The sepsis measures in 2018/19 are directly comparable with 2017/18 measures.
At RUH we are confident that the information we use for monitoring sepsis is accurate. Information is collected from the patient information system within our emergency department and from patient notes. This is then validated by clinical staff and fed back to staff in the department for monitoring performance and driving improvement.
For 2019/20 the work will continue to be taken forward as part of priority 4 - Improvement in early recognition of deteriorating patients and further details on our improvement plans can
153 be found in Section 2.14
In September 2018 a national ‘Suspicion of sepsis ‘dashboard has been produced to track outcomes from patients with all infections termed ‘suspicion of sepsis’. From this dashboard RUH has demonstrated significant improved outcomes for patients with ‘suspicion of sepsis’ diagnoses. This is despite an increase in incidence ‘suspicion of sepsis’ each year.
In 2019 the sepsis team will become a permanent funded SKIP team (sepsis and kidney injury prevention team) to continue to focus on early identification and management.
Cancer Access Targets
Overall the Trust has performed well against cancer targets with the exception of the 62 day target which has not been consistently achieved throughout 2018/19. This is due to a number of factors which are increasing pressure on the target. Within specific tumour sites, the biggest threat to Trust-level performance is from Colorectal and Urology (Prostate specifically) due primarily to an increase in referrals and a change in the nationally recommended diagnostic pathway respectively. Referral rates have increased across the majority of tumour sites as has the requirement for diagnostics. A number of projects are ongoing within the RUH to help improve performance, largely focussed on expediting the diagnostic phase of the pathway for all patients. Some national funding has been provided by NHSE/I to support this work and to support delivery of the new 28 Day Faster Diagnosis Standard which will be measured from April 2019 and performance managed from April 2020.
The performance shown is derived from nationally submitted data to the Cancer Waiting Times data collection and published by NHS England.
154 Summary Hospital Level Mortality Indicator (SHMI)
This is reported as part of the core indicators in part 2.
Hospital Standardised Mortality Ratios (HSMR)
We use the Dr Foster Intelligence benchmarking tool to monitor our HSMR performance. This looks at observed and expected outcomes to measure mortality. The calculation uses statistical methods to identify whether mortality is significantly better, worse or within the expected range of the national average.
We monitor HSMR through our monthly Clinical Outcomes Group meeting that is chaired by the Trist Medical Director and is attended by clinical and non-clinical staff within the Trust. As part of this any areas of concern are investigated.
Due to the time it takes to publish the data we are only able to include figures from April – January 2019. We are pleased to note that our overall HSMR values for April to January 2019 have seen an improvement on 2017/18 and are within the expected range for overall, weekday and weekend mortality Patient Experience
The patient experience indicators are:
1. Referral to Treatment Times 2. Friends and Family 3. Emergency Department Four hour waiting times
Referral to Treatment Times
The Trust has worked hard to balance elective, non-elective and an increase in Cancer referrals throughout 2018/19. This has resulted in us being unable to meet the Open Pathway performance access standard of 92%.
During 2018/19 a new RTT measure was introduced which was to reduce the number of
155 patients on an incomplete pathway from the March 18 to March 19 position. The Trust has met this measure with a 2.4% reduction during the 12 month period.
The contributory factors are related to 2 main causes:
Non- elective demand - as part or winter planning the Trust handed over the elective Orthopaedic ward to support non-elective demand and patient flow, resulting in a 3 month period of reduced elective activity.
Cancer referrals – increase in referrals for suspected cancer who are prioritised over routine referrals resulting in long waits in outpatients.
The Trust has made good progress with surgical specialties including the expansion of chair port now providing day case recovery for more than 60% of all day cases. This has meant that there have been far fewer cancellations and this has improved waiting times for treatment.
The Trust has been working with Commissioners and Independent providers to manage elective care over the year. As part of winter planning the Trust contracted with other providers for Orthopaedic activity as the elective Orthopaedic ward was transferred to support non-elective demand for a 3 month period. In outpatients 2 large volume specialties of Gastroenterology and Dermatology have seen an unprecedented increase in referrals for suspected cancer which has resulted in longer waits and impacted significantly on the ability to meet the 92% standard.
Priority areas for improvement include:
The Trust will continue to work with local system to improve elective services. Aligned to the STP’s prioritisation of outpatient transformation in 2019/20, The Trust will be undertaking an internal Outpatient Improvement Programme, using Improving Together methodology to embed change in the organisation. Through the Acute Hospitals Alliance work will continue in 2019/20 on Get It Right First Time and clinical service reviews in Cardiology and Gastroenterology. Internally, further priority areas of work in 2019/20 include theatre transformation, Chairport (day case elective activity) and paediatric day surgery.
Our workforce plan identifies risks and planned mitigations relating to delivery of the elective activity plan.
The Trust will meet the standard to ensure that the waiting list size at March 2019 remains at the same level as March 2018, and are forecasting to achieve the same standard in March 2020. The Trust is working with commissioners to offer patients waiting over 6 months’ alternative providers, including where the RUH may be offered to patients from other providers.
We are confident that the recording of RTT pathways is robust and includes a number of daily reports to monitor patient pathways. The waiting time performance is derived from nationally submitted Consultant-led Referral To Treatment (RTT) waiting times data that are published by NHS England.
156 Friends and Family
We are confident that our patients have been given the opportunity to provide feedback via the Friends and Family Test (FFT), and that the information displayed represents the responses that we have received. Patients are given the opportunity to complete feedback cards, which are then entered onto our patient experience system. Eligible patient numbers are taken from our Patient Administration System. Responses are eligible populations reported in line with national definitions.
Performance is good and the Friends and Family Test continues to be reported through the Trust Performance and Quality Groups and is on the Trust Scorecard. In addition, the additional comments submitted by patients on the questionnaire are logged and analysed to pick up on any issues. There has been a very small (0.2%) reduction this year in the percentage of patients that would recommend the Emergency Department to friends and family. The response rate for the Emergency Department is low and the department are working to improve this. The Trust also receives feedback about the department through the National Emergency Department survey and through patient contact with the Patient Experience team through the Patient Advice and Liaison services (PALS).
Emergency Department Four hour waiting times
Four-hour performance standard has continued to be challenging for the RUH and the Trust is clear that support from the wider system will continue to be required to further improve delivery. The RUH has continued to draw upon the expertise and experience from those urgent care and emergency systems coping more effectively in order to inform our improvements and planning. In addition, the National Emergency Care Intensive Support Team (ECIST) has been working with the RUH since February 2018, resulting in the RUH urgent and emergency care system developing a system-wide improvement plan with a focus on patient length of stay, in particular those with a stay exceeding 21 days, Home First
157 capacity and alternatives to admission. The improvement programme is led by the Executive Urgent Care Collaborative Board which has responsibility to oversee the improvement plans and actions.
We remain committed to delivering safe and high quality care to our patients and in particular, during the periods of heightened pressure within our Emergency Department. Focus in year has been on the provision of alternative pathways to admission through paediatrics, surgical and medical ambulatory care and direct admission pathways to reduce the number of patients in the Emergency Department. Services have been sustained in paediatrics and surgery, however further work is planned to increase the medical direct admission capacity in 2019/20. 26% of the medical take is now routinely cared for through the ambulatory care service.
In 2019/20 the RUH priorities include:
Developing new clinical pathways to support urgent care patients, including the Bath Urgent Treatment Centre, development of an ambulatory care assessment pathway for trauma patients and improved direct admit pathways in to our Medical Assessment Unit.
Further step change focus on improving discharge pathways, building on progress to date. In particular Super Discharge Weeks, and working with partners on further reducing the length of stay for patients with a delayed transfer of care.
Implementation of the new Patient Flow digital capacity management system to optimise the benefits for patient flow, including the new side room tool to support infection control.
With a higher than national average elderly population, improving care for frail patients is central to our plans, including continued development of the Frailty Flying Squad and a focus in the coming year on developing a Frailty Assessment Unit.
The new modular ward, supporting the Trust’s strategic estates plan, offers a potential mitigation for any bed closures related to the estate, as seen in 2018/19.
In addition the Emergency Department will be focused on improvement in the Royal College of Emergency Medicine Clinical Quality Standards to make further improvements in time to triage, treatment and total time in the department. Front Door teams within the medical division will also form part of Wave Three of the Improving Together programme to support transformation.
The performance shown is based on data submitted to the NHS A&E Attendances and Emergency Admissions data collection published by NHS England.
3.2 Care Quality Commission (CQC)
The Care Quality Commission (CQC) undertook a planned inspection of the Trust in June 2018 and inspected five core services (urgent and emergency services, medical care, critical care, children and young people’s services). The CQC also reviewed management and leadership of the Trust to answer the key question about whether the Trust is well led.
158 The CQC rated the Trust overall as ‘Good’, an improvement from the ‘Requires Improvement’ rating achieved during the last comprehensive inspection in March 2016. A full overview of the ratings are shown below.
The overall rating for caring remained as ‘outstanding’ with the CQC recognising that the care provided to patients and their families was kind, compassionate and sensitive to patient needs. The Trust was rated as ‘Good’ overall for being well-led. This was because there was a clear vision and strategy to deliver high quality, sustainable care to people who use services. There were clear governance processes in place that ensured the quality and safety of patients were monitored, risks identified and action taken to address these. The CQC also noted that there was active engagement with patients, carers and staff.
The inspection report identifies many areas of good and outstanding practice including maternity care with the CQC noting that the person-centred culture was evident and the care and support that women and their partners received often exceeded expectations. The CQC also recognised, for example, that quality improvement was embedded within the Emergency Department (ED) and department leads were committed to the development of staff and the exceptional multidisciplinary working within children’s and young people’s services.
Within critical care the CQC noted that there were sufficient numbers of appropriately trained staff to meet patient needs. People were protected from abuse and neglect, there was good multidisciplinary working, staff adhered to infection control processes and there was a positive incident reporting culture on the unit, lessons were learned and action taken to improve practice.
159 Within medical care the CQC commented on how information from complaints, incidents and audit was used to improve services. Staff felt supported to speak up about any concerns they had and to develop initiatives to improve patient care.
For services for children and young people the CQC recognised that there were clearly defined and embedded systems, processes and practices to keep children safe and safeguarded from abuse. The CQC also noted the exceptional multidisciplinary working and care provided to babies, children, young people and their families. There were clear responsibilities, roles and processes to support effective governance with leaders demonstrating a clear vision and strategy for the service and having the skills, knowledge and experience to lead the service.
The rating for Urgent and Emergency services remains as ‘Requires Improvement’ with the CQC finding that sufficient improvements had not been made to key areas identified in the last inspection report that impacted on patient care. The CQC noted that the department remained over-crowded, patients were waiting too long on trolleys and risks to patient flow were still concentrated on the emergency department, rather than being shared through the system.
The CQC identified four actions where the Trust must improve, all related to urgent and emergency services. An improvement plan was developed and returned to the CQC detailing the actions to address the four compliance recommendations from the inspection report. Implementation of this improvement plan is monitored on a quarterly basis through Management Board and the Board of Directors. The following table shows progress achieved to date in addressing the CQC recommendations.
Urgent and Emergency Services
CQC recommendation Improvements made Ensure the systems designed to Weekly audits on compliance for completion of the protect children from harm and safeguarding screening tool (reviewed by Emergency abuse are working effectively and Department Paediatric Safeguarding reviewers). processes are fully documented, especially during times of pressure. Weekly report produced for how up to date the The Trust must improve staff Paediatric reviewing for assessment of children awareness of ‘Think Family’ presenting to the Emergency Department. principles in the Urgent Treatment Centre (UTC). Administration system set up to ensure reviewing nurses are reviewing those individual cases where the safeguarding screening tool has not been completed.
Safeguarding referral process in the Urgent Treatment Centre has been amended: step by step guidance available to staff.
Safeguarding supervision sessions available for staff (attendance should be at least twice yearly). Compliance with this requirement monitored through
160 CQC recommendation Improvements made the Urgent Treatment Centre Governance meetings.
Adult and child link nurses in post who work closely with the RUH safeguarding team. The Trust must resolve issues Data accuracy for time to initial assessments preventing the collection of reliable investigated with both Business Intelligence Unit (BIU) data regarding time to initial and front-line staff. assessment for ambulance and self- presenting patients. Ensure staff Dedicated ring-fenced triage nurse in minors. report treatment delays on the adverse incident reporting system. BIU report produced daily on time to initial assessment (disseminated to senior Emergency Department nursing team and triumvirate and divisional leads). This is also included on the weekly Urgent Care scorecard.
Daily BIU report produced and DATIX risk assessment submitted for number of patients nursed in the corridor (this does not currently include patient identifiable information). This is also included on the weekly Urgent Care scorecard. Provide staff who are involved in the Training Needs Analysis developed which identifies assessment of children in the urgent which staff have received paediatric training. care centre appropriate training in paediatric assessment in line with Paediatric master classes are being developed for the recommendations of the Royal Emergency Department and Urgent Treatment Centre College of Paediatrics and Child staff (held 4 times a year), which include key Health. Ensure suitable numbers of Paediatric competencies. medical and nurse staff are provided. This must ensure safe nurse to Work undertaken with the Emergency Care patient ratios can be maintained at Improvement Programme to provide a medical predictably busy times and there are staffing model. sufficient medical staff to maintain safe staffing levels and treat patients Workforce planning will be mapped with the deputy in line with best practice guidance. divisional manager / Emergency Department specialty manager and Emergency Department Matron. Improve the time taken to treat, Standard Operating Procedure produced for use of discharge or admit patients to be the safety checklist (to be rolled out). compliant with the performance improvement plan agreed with NHS Weekly snapshot audits undertaken on completion of Improvement. Improve the flow of the safety checklist and NEWS. patients requiring admission to the medical wards to reduce the length Actions related to patient flow work to continue to be of time patients wait on trolleys after reported and monitored through the Urgent Care admission has been agreed. Ensure Collaborative.
161 CQC recommendation Improvements made patients are checked regularly whilst waiting in the department and that Increased direct admits to Medicine and Surgery this is recorded on the observation through ring-fencing areas on Medical Admissions chart and safety checklist escalation Unit and Surgical Assessment Unit. pro-forma. Fit to sit chairs introduced on the Emergency Department Observations Unit.
Emergency Department full capacity protocol established in September 2018 limiting the number of patients in the corridor.
3.3 Commissioning for Quality and Innovation (CQUIN)
The Commissioning for Quality and Innovation (CQUIN) is a payment framework which enables Commissioners to reward excellence by linking a proportion of acute healthcare provider’s income conditional on demonstrating improvements in quality in specified areas of care. For 2018/19 all schemes have been nationally mandated and applied to all acute Trusts.
Where relevant the scheme is led by a clinician, who supports the achievement of the quality indicator milestones and is accountable for the financial performance of the scheme. The following outlines the progress with the 2018/2019 CQUIN schemes.
National CQUIN schemes for 2018/19
Overview of 2018/19 CQUIN achievements:
162 Staff Health and Wellbeing
This scheme is comprised of three parts in support of the Five Year Forward View commitment ‘to ensure the NHS as an employer sets a national example in the support it offers its own staff to stay healthy’. Oversight of the schemes was via the Health and Wellbeing Group which is chaired by the Deputy Director of Human Resources and members continue to work towards its achievement and also other wider initiatives to support staff health and wellbeing in the Trust.
The scheme was split into three parts; Improving Health and Wellbeing of NHS Staff Healthy food for NHS staff, visitors and patients Improving the uptake of flu vaccinations for frontline clinical staff within Providers
Improving Health and Wellbeing of NHS Staff
The Trust continues to work towards supporting both the physical and mental health and wellbeing of its staff, this is monitored via the NHS Annual Staff Survey where the Trust is required to evidence improvement in the staff responses to three questions: 1. Does your organisation take positive action on health and well-being? 2. In the last 12 months have you experienced musculoskeletal problems (MSK) as a result of work activities? 3. During the last 12 months have you felt unwell as a result of work related stress?
During the year the Staff Health and Wellbeing Group promoted and hosted a range of wellbeing initiatives including the Trust’s Health and Wellbeing Festival in September 2018 which offered staff; free swimming and exercise sessions, trolley dashes to wards in the evening with leaflets and healthy snacks for staff and there was a wide range of opportunities for staff to inform themselves on a range of topics such as pelvic health, hydration, sepsis and kidney health. Our Employee Assistance Program (EAP) team were on hand to provide stress MOT sessions, and Occupational Health colleagues gave health checks.
Staff also have access to information and support via a dedicated Health and Wellbeing intranet webpage which covers a wide range of topics from accommodation, stress management, staff physiotherapy and occupational health as examples.
The Trust is disappointed not to have reached the 5% point improvement in two of the three NHS annual staff survey questions laid out by the scheme when compared to the baseline from 2016 and did not achieve the CQUIN as a consequence. The table below demonstrates the 2018 results:
Question 2016 result (%) 2018 result (%) Change Does your organisation take positive 31.16% responding 28.41% -2.75% action on health and well-being? 'Yes, definitely' responding 'Yes, definitely' In the last 12 months have you 76.07% responding 71.93% -4.14% experienced musculoskeletal problems 'no' responding 'no' (MSK) as a result of work activities?
163 In the last 12 months have you felt 65.41% responding 63.66% -1.75% unwell as a result of work related stress? 'no' responding 'no'
The Trust has a number of support events planned for this year including: 13-19 May 2019 Mental Health Awareness 24-29 September 2019 Annual Health & Wellbeing Festival, including: well-being MOT checks; advice on mental wellbeing / mindfulness and sleep and a soft-launch of the Flu Campaign. 18 October 2019 – World Menopause Day – Café-style event We are also working towards a revamp and promotion of the improved health & wellbeing pages both internally and externally.
Healthy food for NHS staff, visitors and patients
It is important for the NHS to start leading the way on tackling obesity and the consumption of sugar and sugar sweetened drinks, starting with the food and drink that is provided and promoted in hospitals to staff, visitors and patients. This scheme required the Trust and retail partners to: 1. Ensure a ban on advertising sugary drinks and foods high in fat, sugar and salt had been maintained from the previous year 2. Make a commitment to the national Sugar Sweetened Beverage (SSB) reduction scheme and ensure that the total litres of SSB accounted for less than 10% or less of all litres sold 3. Ensure confectionary and sweets sold did not exceed 250 Kcal per packet 4. 75% of pre- packed sandwiches and savoury meals contained 400kcal or less and 5g of saturated fat
The Trust and its charitable Friends of the RUH partner has maintained its commitment to providing healthy food and drink to staff, visitors and patients by implementing all of the above requirements. The catering department has a longstanding commitment to providing fresh, traceable food that meets nutritional guidelines and continues to be accredited with a SOIL Association ‘Food for life’ award, alongside this the Patient Catering Team was awarded the 2018 New Year’s Honours ‘Team of the Year Award’.
Improving the uptake of flu vaccinations for frontline clinical staff
The Trust was required to achieve an uptake of the flu vaccination by 75% of frontline clinical staff by February 2019. The campaign ran from October 2018 to February 2019 and focussed on each clinician’s responsibility to protect themselves and those around them from the virus, but has also incentivised staff by ensuring the vaccine is as easy as possible to receive. The vaccination team for the Trust has been led by the Flu Vaccination Scheme Board and Occupational Health and Wellbeing Nurse Manager.
The Trust has achieved an uptake in vaccinations of 70.2% of front line clinical staff with 75.4% substantive frontline staff.
164 Reducing the impact of serious infections (Antimicrobial Resistance and Sepsis)
A scheme aimed at continuing the Trust’s excellent track record in swiftly identifying and treating sepsis which was recognised by being shortlisted for an HSJ award in 2018, the scheme also focussed on combating the rise of antimicrobial resistance by reducing the overuse and inappropriate prescription of antimicrobials.
The sepsis safety programme has been an ongoing priority in the Trust since 2014. The scheme focuses on the rapid detection, via screening, and treatment of patients with Sepsis in the Emergency Department and inpatient settings. As a result of this work we are now identifying patients earlier and administering antibiotics faster.
In November 2018 NEWS2 (National Early Warning Score) was implemented Trust-wide in line with CQUIN and patient safety alert requirements.
The Trust continues to provide high numbers of antibiotic reviews by appropriate clinicians and is working towards the reduction of antibiotic consumption per 1,000 admissions and proportion of broad spectrum antibiotic use. To further support the scheme, from January 2019 the Trust is taking part in ARK (Antibiotic Review Kit), a national research programme to test implementation of a package of measures to help healthcare staff stop antibiotics when they are no longer needed.
Improving services for people with mental health needs who present to the Emergency Department
The Trust continues to work in partnership with our Mental Health provider to identify and review patients who have attended the Emergency Department on multiple occasions who may have underlying mental health needs who may benefit from care in a more appropriate setting.
Patients have been identified jointly by clinical leads from the RUH and Avon & Wiltshire Mental Health Partnership NHS Trust, who would benefit from the creation of a joint care plan which was then created by a multi-disciplinary team, including members from the Emergency Department community mental health team, local Ambulance Trust and others. Care plans are shared with member organisations participating in the multi-disciplinary team (MDT) for dissemination to clinical colleagues, as appropriate, to support co-ordinated care across organisations. Where relevant the patient’s GP is engaged before a review by the MDT and followed up after depending on the patient’s presentation.
In-year reporting has evidenced a high percentage of patients who received care plans went on to reduce their attendances to the Emergency Department.
Offering Advice and Guidance
The scheme requires the Trust to operate an Advice & Guidance service for non-urgent GP referrals, allowing GPs to access consultant advice prior to referring patients into the hospital.
165 The Trust currently offers access to clinicians in 21 elective specialties and three Acute Connect services covering Medicine Advice, referrals and Surgical Admissions
Since the launch of the telephony service, Trust clinicians have answered over 12,000 calls with an average connection time of 00:39 seconds and 03:39 minutes call length. This means that over 75% of specialities who receive GP referrals offer an advice and guidance service with over 70% of calls answered first time.
Preventing ill health by risky behaviours – alcohol and tobacco
Smoking is estimated to cost £13.8bn to society and £2bn on the NHS through hospital admissions, £7.5bn through lost productivity, £1.1bn in social care. Smoking is England’s biggest killer, causing nearly 80,000 premature deaths a year and a heavy toll of illness, 33% of tobacco is consumed by people with mental health problems. The focus of the scheme was to identify patients who disclosed themselves as smokers or who consume alcohol above the lower risk level and offer advice and guidance or support with accessing cessation services.
The Trust undertook to build a system to record data on patients. A Healthy Choices team was established who consist of specially trained support staff who are responsible for contacting the patient whilst they are still in hospital, to offer them further advice and nicotine replacement products, and onward referral to the community cessation services. The team is supervised by the Trust’s in-house smoking cessation and alcohol liaison services who are on hand to lead on any particularly complex cases and offer further support to the team.
Making Every Contact Count (MECC) – Urgent Treatment Centre
A scheme to improve the health of the population by using every contact with an individual to maintain or improve their mental and physical health and wellbeing. Clinicians in the Urgent Treatment Centre ensured that service users who have lifestyle risk factors e.g. smoking, alcohol misuse, physical inactivity, obesity etc. are identified, provided with brief opportunistic advice which is empowering and culturally sensitive, and signposted or referred to local healthy lifestyle services. The Trust undertook to implement a programme of education for staff in the Urgent Treatment Centre to support them with Making Every Contact Count. Strong links were developed with other healthy lifestyle services within the Trust and a continual programme of staff engagement and learning embedded.
Stroke Pathways – Engagement across the Sustainability and Transformation region
This scheme sought to support Stroke teams across Bath and North East Somerset, Wiltshire and Swindon to engage in Collaborative meetings and agreed improvement work. Providers submit data to the Sentinel Stroke National Audit Programme (SSNAP) which was reviewed to benchmark and identify areas of system wide improvement. The aim is to improve outcomes for stroke patients and reduce variation.
Medicines Optimisation
This scheme aims to support the procedural and cultural changes required to optimise the use of medicines commissioned by specialised services. The following priority areas for
166 implementation have been identified nationally by clinical leaders, commissioners, Trusts, the Carter Review and the National Audit Office, namely:
Faster adoption of best value medicines with a particular focus on the uptake of best value generics, biologics and Commercial Medicines Unit frameworks as they become available Significantly improved drugs data quality The consistent application of lowest cost dispensing channels Compliance with policy/ consensus guidelines to reduce variation and waste.
The pharmacy team have worked with clinical teams across the hospital to amend prescribing practice when new medicines are approved and put in place additional processes to ensure all appropriate data is captured and reviewed. The Trust also undertook a procurement exercise to select a provider for the pharmacy shop located in the Atrium.
Nationally Standardised Dose Banding Adult Intravenous (SACT)
Chemotherapy is the single biggest service area within NHS England’s specialised commissioning budget traditionally, chemotherapy doses have been unique to individual patients based on a weight calculation. Such specific dosing does not provide additional clinical or patient benefit and significantly increases time and costs of preparation and costs of drug wastage. The NHS England scheme sought to standardise doses of prescribed chemotherapy to reduce variation in prescribing as part of the national medicines optimisation agenda.
The scheme required the clinical teams to support the principle of dose banding of adult intravenous systemic anticancer therapy and then increase the percentage of dose banded prescriptions administered.
Optimising Palliative Chemotherapy Decision
A scheme focused on ensuring that in cases where chemotherapy was being used to treat palliative patients, a peer to peer discussion had taken place and been recorded. This should ensure decisions to start and continue further treatment should be made in direct consultation with peers and then as a shared decision with the patient.
Over the course of the year the team have developed a rolling programme of education to support clinicians to record peer to peer conversations and continued to embed the existing processes for 30 day mortality reviews and how two specific groups of patients are recorded.
3.4 Duty of Candour
In November 2014, it became a legal requirement for all NHS Trusts to implement Duty of Candour. This was an important step towards ensuring an open, honest and transparent culture.
The intention of this regulation is to ensure that providers are open and transparent with people who use services and other 'relevant persons' (people acting lawfully on their behalf)
167 in relation to care and treatment. It sets out specific requirements that providers must follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology when things go wrong. It is important that lessons are learned and improvements made when things go wrong and that the culture of the organisation encourages openness and transparency. The CQC reviewed Duty of Candour as part of its inspection of the Trust in June 2018 and noted that there was evidence that the Duty of Candour regulations had been complied with and staff they spoke to had a good understanding of the requirements.
To ensure compliance, the Trust has produced a Duty of Candour policy to guide staff. The Trust Risk and Assurance team provide support to staff to ensure they are compliant with the process as per the policy.
Duty of Candour has been incorporated into the Trust’s incident reporting system. Moderate, Severe and Catastrophic patient safety incidents automatically trigger Duty of Candour ‘fields’ which have to be completed by the incident reporter and informs relevant staff of required actions they need to take. Duty of Candour is embedded in the process of investigating incidents. The risk team advise the Patient Safety Managers within each division of outstanding Duty of Candour actions relating to the sharing of investigation findings.
The Trust conducts Duty of Candour audits where incidents are reviewed in order to assess whether the requirements of the regulation are being met and ensure the correct procedure has been followed.
On a quarterly basis, a review of those incidents for which the reporter has indicated that Duty of Candour is not applicable, is performed. If it is discovered that Duty of Candour should have been implemented, the Duty of Candour action chain is initiated and the reporter of the incident contacted to explain why the previous decision has been overturned.
In January 2019 KPMG commenced an external audit relating to the implementation and compliance with duty of candour. The Trust will review their findings and any recommendations made.
3.5 Additional considerations:
1. Statement regarding progress in implementing the priority clinical standards for 7 day hospital services. This progress should be assessed as guided by the seven day hospital services board assurance framework published by NHSI
We are compliant with all seven day standards except clinical standards 2 and 6. For standard 2 in April 2018 our weekday compliance was 84% and weekend compliance was 50%, giving an overall compliance of 76%. We are altering the job plans of consultants and improving documentation of consultant ward rounds to improve this standard. In standard 6 we are non-complaint due to interventional radiology provision. This is a regional problem which we are working with our partner hospitals to solve.
168 2. In its response to the Gosport Independent Panel Report, the Government committed to legislation requiring all NHS trusts and NHS foundation trusts in England to report annually on staff who speak up (including whistleblowers). Ahead of such legislation, NHS trusts and NHS foundation trusts are asked to provide details of ways in which staff can speak up (including how feedback is given to those who speak up), and how they ensure staff who do speak up do not suffer detriment. This disclosure should explain the different ways in which staff can speak up if they have concerns over quality of care, patient safety or bullying and harassment within the trust.
The Trust revised its Raising Concerns Policy during 2018/19 to ensure it was in line with the national best practice.
In many circumstances the easiest way for an individual to get a concern resolved will be to raise it formally or informally with their line manager (or lead clinician or tutor), but where this is not appropriate, individuals can contact the Trust Freedom to Speak Up Guardian who is an independent and impartial source of advice to staff at any stage of raising a concern, with access to anyone in the organisation, including the Chief Executive, or if necessary, outside the organisation.
Individuals can also speak to any of the Local Freedom to Speak Up Guardians who support the Trust Freedom to Speak Up Guardian and provide an additional route, locally, to raise concerns. A member of the risk management team or our Board of Directors’ Secretary can also be contacted. If the concern remains after this, the Director of People is the Trust’s Executive Director with responsibility for whistleblowing and the Chief Executive, Chairman or Non-Executive Director with responsibility for whistleblowing may also be contacted.
These individuals treat concerns confidentially unless otherwise agreed; ensure timely support to progress the concern; escalate to the board any indications that the individual raising the concern is being subjected to detriment for raising the concern; remind the organisation of the need to provide timely feedback on how the concern is being dealt with; ensure access to personal support.
If an individual raises a genuine concern under the Freedom to Speak Up: Raising Concerns Policy, they will not be at risk of losing their job or suffering any form of reprisal as a result. The Trust, led by the Board of Directors, will not tolerate the harassment or victimisation of anyone raising a concern. Nor tolerate any attempt to bully them into not raising any such concern
Organisations are reminded that schedule 6, paragraph 11b of the Terms and Conditions of Service for NHS Doctors and Dentists in Training (England) 2016 requires “a consolidated annual report on rota gaps and the plan for improvement to reduce these gaps shall be included in a statement in the Trust's Quality Account
The Guardian of Safe Working reports to Board on a quarterly basis which is shared with the Joint Local Negotiating Committee and Medical Workforce Planning Group. The reports include data on all rota gaps. In addition, the Guardian provides a consolidated annual report to Board outlining all rota gaps and any improvement plans in place.
169 Statements from NHS England or relevant CCG local Healthwatch organisation, & overview & scrutiny committees
A statement of directors responsibilities for the quality report
170 ANNEX 1: STATEMENTS FROM NHS ENGLAND OR RELEVANT CCG, LOCAL HEALTHWATCH ORGANISATIONS, & OVERVIEW & SCRUTINY COMMITTEES
171 172 173 174 175 176 177 ANNEX 2: STATEMENT OF DIRECTORS RESPONSIBILITIES FOR THE QUALITY REPORT
The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations to prepare Quality Accounts for each financial year.
NHS Improvement has issued guidance to NHS foundation Trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation Trust boards should put in place to support the data quality for the preparation of the quality report.
In preparing the quality report, directors are required to take steps to satisfy themselves that:
the content of the quality report meets the requirements set out in the NHS foundation Trust annual reporting manual 2018/19 and supporting guidance Detailed requirements for quality reports 2018/19;
the content of the quality report is not inconsistent with internal and external sources of information including:
o board minutes and papers for the period 01 April 2018 to 31 March 2019;
o papers relating to quality reported to the board over the period 01 April 2018 to 31 March 2019;
o feedback from commissioners dated 07/05/2019;
o feedback from governors dated 09/01/2019;
o feedback from local Healthwatch organisations dated 02/05/2019;
o feedback from overview and scrutiny committee dated 15/04/2019;
o the Trust’s complaints report published under Regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 25 July 2018;
o 2017 and 2018 national patient surveys;
o 2017 and 2018 national staff surveys;
o the Head of Internal Audit’s annual opinion of the Trust’s control environment dated 21/05/2019;
o CQC inspection report dated 26 September 2018;
the quality report presents a balanced picture of the NHS foundation Trust’s performance over the period covered;
the performance information reported in the quality report is reliable and accurate;
178 there are proper internal controls over the collection and reporting of the measures of performance included in the quality report, and these controls are subject to review to confirm that they are working effectively in practice;
the data underpinning the measures of performance reported in the quality report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review;
the quality report has been prepared in accordance with NHS Improvement’s annual reporting manual and supporting guidance (which incorporates the quality accounts regulations) as well as the standards to support data quality for the preparation of the quality report.
The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the quality report.
By order of the board.
...... 21 May 2019...... Date...... Chair
...... 21 May 2019...... Date...... Chief Executive
179 Independent auditor’s report to the council of governors of Royal United Hospitals Bath NHS Foundation Trust on the quality report
We have been engaged by the council of governors of Royal United Hospitals Bath NHS Foundation Trust to perform an independent assurance engagement in respect of Royal United Hospitals Bath NHS Foundation Trust’s quality report for the year ended 31 March 2019 (the ‘quality report’) and certain performance indicators contained therein.
This report, including the conclusion, has been prepared solely for the council of governors of Royal United Hospitals Bath NHS Foundation Trust as a body, to assist the council of governors in reporting Royal United Hospitals Bath NHS Foundation Trust’s quality agenda, performance and activities. We permit the disclosure of this report within the Annual Report for the year ended 31 March 2019, to enable the council of governors to demonstrate they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the council of governors as a body and Royal United Hospitals Bath NHS Foundation Trust for our work or this report, except where terms are expressly agreed and with our prior consent in writing.
Scope and subject matter The indicators for the year ended 31 March 2019 subject to limited assurance consist of the national priority indicators as mandated by NHS Improvement: percentage of patients with a total time in A&E of four hours or less from arrival to admission, transfer or discharge, and maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers, reported in accordance with official performance statistics based on 50:50 breach allocation rules.
We refer to these national priority indicators collectively as the ‘indicators’.
Respective responsibilities of the directors and auditors The directors are responsible for the content and the preparation of the quality report in accordance with the criteria set out in the ‘NHS foundation trust annual reporting manual’ issued by NHS Improvement. Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that:
the quality report is not prepared in all material respects in line with the criteria set out in the ‘NHS foundation trust annual reporting manual’ and supporting guidance; the quality report is not consistent in all material respects with the sources specified in NHS foundation trust annual reporting manual; and the indicators in the quality report identified as having been the subject of limited assurance in the quality report are not reasonably stated in all material respects in accordance with the ‘NHS foundation trust annual reporting manual’ and the six dimensions of data quality set out in the ‘Detailed guidance for external assurance on quality reports’.
We read the quality report and consider whether it addresses the content requirements of the ‘NHS foundation trust annual reporting manual’ and supporting guidance, and consider the implications for our report if we become aware of any material omissions.
We read the other information contained in the quality report and consider whether it is materially inconsistent with: board minutes for the period April 2018 to 21 May 2019; papers relating to quality reported to the board over the period April 2018 to 21 May 2019; feedback from Commissioners, dated May 2019; feedback from governors, dated May 2019; feedback from local Healthwatch organisations, dated May 2019; the trust’s latest complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated July 2018; the 2018 national patient survey; the 2018 national staff survey; Care Quality Commission inspection report, dated December 2018; the Head of Internal Audit’s annual opinion over the trust’s control environment, dated May 2019; and any other information included in our review.
180 We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with those documents (collectively the ‘documents’). Our responsibilities do not extend to any other information.
We are in compliance with the applicable independence and competency requirements of the Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team comprised assurance practitioners and relevant subject matter experts.
Assurance work performed We conducted this limited assurance engagement in accordance with International Standard on Assurance Engagements 3000 (Revised) – ‘Assurance Engagements other than Audits or Reviews of Historical Financial Information’ issued by the International Auditing and Assurance Standards Board (‘ISAE 3000’). Our limited assurance procedures included:
evaluating the design and implementation of the key processes and controls for managing and reporting the indicators; making enquiries of management; testing key management controls; limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation; comparing the content requirements of the ‘NHS foundation trust annual reporting manual’ to the categories reported in the quality report; and reading the documents.
A limited assurance engagement is smaller in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement.
Limitations Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information. The absence of a significant body of established practice on which to draw allows for the selection of different, but acceptable measurement techniques which can result in materially different measurements and can affect comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision of these criteria, may change over time. It is important to read the quality report in the context of the criteria set out in the ‘NHS foundation trust annual reporting manual’ and supporting guidance. The scope of our assurance work has not included testing of indicators other than the two selected mandated indicators, or consideration of quality governance.
Conclusion Based on the results of our procedures, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2019:
the quality report is not prepared in all material respects in line with the criteria set out in the ‘NHS foundation trust annual reporting manual’ and supporting guidance; the quality report is not consistent in all material respects with the sources specified in NHS foundation trust annual reporting manual; and the indicators in the quality report subject to limited assurance have not been reasonably stated in all material respects in accordance with the ‘NHS foundation trust annual reporting manual’ and supporting guidance.
Deloitte LLP Birmingham
21 May 2019
181 Royal United Hospitals Bath NHS Foundation Trust
Annual accounts for the year ended 31 March 2019
182 Foreword to the accounts
Royal United Hospitals Bath NHS Foundation Trust
These accounts, for the year ended 31 March 2019, have been prepared by Royal United Hospitals Bath NHS Foundation Trust in accordance with paragraphs 24 & 25 of Schedule 7 within the National Health Service Act 2006.
Signed
James Scott Chief Executive Date 21st May 2019
183 Statement of Comprehensive Income For Year Ended 31 March 2019 Group 2018/19 2017/18 Note £000 £000 Operating income from patient care activities 3 306,433 282,727 Other operating income 4 49,386 44,379 Operating expenses 5, 8 (333,677) (316,567) Operating surplus from continuing operations 22,142 10,539 Finance income 11 364 214 Finance expenses 12 (301) (311) PDC dividends payable (5,555) (4,888) Net finance costs (5,492) (4,985) Other gains / (losses) 13 (77) 15,240 Surplus for the year from continuing operations 16,573 20,794 Surplus on discontinued operations and the gain on disposal of discontinued operations - - Surplus for the year 16,573 20,794
Other comprehensive income Will not be reclassified to income and expenditure: Revaluations 18 472 2,558
May be reclassified to income and expenditure when certain conditions are met: Fair value gains/(losses) on financial assets mandated at fair value through OCI 19 191 (1) Total comprehensive income for the period 17,236 23,351
Surplus for the period attributable to: Royal United Hospitals Bath NHS Foundation Trust 16,573 20,794 TOTAL 16,573 20,794
Total comprehensive income for the period attributable to: Royal United Hospitals Bath NHS Foundation Trust 17,236 23,351 TOTAL 17,236 23,351
18 4 Statement of Financial Position For Year Ended 31 March 2019 Group Trust 31 March 31 March 31 March 31 March 2019 2018 2019 2018 Note £000 £000 £000 £000 Non-current assets Intangible assets 15 9,921 9,706 9,921 9,706 Property, plant and equipment 16 200,147 176,109 200,147 176,109 Other investments / financial assets 19 8,512 7,128 - - Receivables 23 1,785 1,534 1,182 1,134 Total non-current assets 220,365 194,477 211,250 186,949 Current assets Inventories 22 3,000 4,322 3,000 4,322 Receivables 23 30,121 24,580 31,889 24,741 Cash and cash equivalents 24 22,331 35,504 18,946 32,912 Total current assets 55,452 64,406 53,835 61,975 Current liabilities Trade and other payables 25 (28,502) (29,144) (28,395) (29,144) Borrowings 26 (3,424) (3,052) (3,424) (3,052) Provisions 29 (335) (2,149) (335) (2,149) Other liabilities 26 (5,691) (4,756) (5,691) (4,756) Total current liabilities (37,952) (39,101) (37,845) (39,101) Total assets less current liabilities 237,865 219,782 227,240 209,823 Non-current liabilities Borrowings 26 (13,771) (15,127) (13,771) (15,127) Provisions 29 (763) (784) (763) (784) Total non-current liabilities (14,534) (15,911) (14,534) (15,911) Total assets employed 223,331 203,871 212,706 193,912
Financed by Public dividend capital 159,070 156,846 159,070 156,846 Revaluation reserve 44,601 42,237 44,601 42,237 Income and expenditure reserve 9,035 (5,171) 9,035 (5,171) Charitable fund reserves 21 10,625 9,959 - - Total taxpayers' equity 223,331 203,871 212,706 193,912
The notes on pages 11 to 59 form part of these accounts.
James Scott Chief Executive Date 21st May 2019
185 Statement of Changes in Equity For Year Ended 31 March 2019 Public Financial Income and Charitable dividend Revaluation assets Other Merger expenditure fund Group capital reserve reserve* reserves reserve reserve reserves Total £000 £000 £000 £000 £000 £000 £000 £000 Taxpayers' and others' equity at 1 April 2018 - brought forward 156,846 42,237 - - - (5,171) 9,959 203,871 Surplus for the year - - - - - 16,098 475 16,573 Other transfers between reserves - 1,892 - - - (1,892) - - Revaluations - 472 - - - - - 472 Fair value gains on financial assets mandated at fair value through OCI ------191 191 Public dividend capital received 2,224 ------2,224 Taxpayers' and others' equity at 31 March 2019 159,070 44,601 - - - 9,035 10,625 223,331
186 Statement of Changes in Equity For Year Ended 31 March 2018 Available for Public sale Income and Charitable dividend Revaluation investment Other Merger expenditure fund Group capital reserve reserve reserves reserve reserve reserves Total £000 £000 £000 £000 £000 £000 £000 £000 Taxpayers' and others' equity at 1 April 2017 - brought forward 152,084 41,098 - - - (25,930) 8,506 175,758 Surplus for the year - - - - - 18,579 2,215 20,794 Other transfers between reserves - (796) - - - 796 - - Revaluations - 2,558 - - - - - 2,558 Transfer to retained earnings on disposal of assets - (623) - - - 623 - - Fair value losses on available-for-sale financial investments ------(1) (1) Public dividend capital received 4,762 ------4,762 Other reserve movements - - - - - 761 (761) - Taxpayers' and others' equity at 31 March 2018 156,846 42,237 - - - (5,171) 9,959 203,871
187 Statement of Changes in Equity For Year Ended 31 March 2019 Public Financial Income and dividend Revaluation assets Other Merger expenditure Trust capital reserve reserve* reserves reserve reserve Total £000 £000 £000 £000 £000 £000 £000 Taxpayers' and others' equity at 1 April 2018 - brought forward 156,846 42,237 - - - (5,171) 193,912 Surplus for the year - - - - - 16,098 16,098 Other transfers between reserves - 1,892 - - - (1,892) - Revaluations - 472 - - - - 472 Public dividend capital received 2,224 - - - - - 2,224 Taxpayers' and others' equity at 31 March 2019 159,070 44,601 - - - 9,035 212,706
188 Statement of Changes in Equity For Year Ended 31 March 2018 Available for Public sale Income and dividend Revaluation investment Other Merger expenditure Trust capital reserve reserve reserves reserve reserve Total £000 £000 £000 £000 £000 £000 £000 Taxpayers' and others' equity at 1 April 2017 - brought forward 152,084 41,098 - - - (25,930) 167,252 Prior period adjustment ------Taxpayers' and others' equity at 1 April 2017 - restated 152,084 41,098 - - - (25,930) 167,252 Surplus for the year - - - - - 18,579 18,579 Other transfers between reserves - (796) - - - 796 - Revaluations - 2,558 - - - - 2,558 Transfer to retained earnings on disposal of assets - (623) - - - 623 - Public dividend capital received 4,762 - - - - - 4,762 Other reserve movements - - - - - 761 761 Taxpayers' and others' equity at 31 March 2018 156,846 42,237 - - - (5,171) 193,912
189 Information on reserves
Public dividend capital Public dividend capital (PDC) is a type of public sector equity finance based on the excess of assets over liabilities at the time of establishment of the predecessor NHS organisation. Additional PDC may also be issued to trusts by the Department of Health and Social Care. A charge, reflecting the cost of capital utilised by the Trust, is payable to the Department of Health as the public dividend capital dividend.
Revaluation reserve Increases in asset values arising from revaluations are recognised in the revaluation reserve, except where, and to the extent that, they reverse impairments previously recognised in operating expenses, in which case they are recognised in operating income. Subsequent downward movements in asset valuations are charged to the revaluation reserve to the extent that a previous gain was recognised unless the downward movement represents a clear consumption of economic benefit or a reduction in service potential.
Income and expenditure reserve The balance of this reserve is the accumulated surpluses and deficits of the Trust.
Charitable funds reserve This reserve comprises the ring-fenced funds held by the NHS charitable funds consolidated within these financial statements. These reserves are classified as restricted or unrestricted; a breakdown is provided in note 21.
190 Statement of Cash Flows For Year Ended 31 March 2019 Group Trust 2018/19 2017/18 2018/19 2017/18 Note £000 £000 £000 £000 Cash flows from operating activities Operating surplus / (deficit) 22,142 10,539 21,872 3,966 Non-cash income and expense: Depreciation and amortisation 5 10,253 8,679 10,253 8,679 Net impairments 7 1,844 (1,853) 1,844 (1,853) Income recognised in respect of capital donations 4 (1,964) (24) (1,964) (735) (Increase) / decrease in receivables and other assets (6,123) (1,061) (7,538) 4,070 (Increase) / decrease in inventories 1,322 (656) 1,322 (656) Increase / (decrease) in payables and other liabilities (1,040) 4,300 (1,040) 4,300 Increase / (decrease) in provisions (1,843) 1,243 (1,843) 1,243 Movements in charitable fund working capital 878 (619) - - Other movements in operating cash flows 23 94 (1) 44 Net cash flows from / (used in) operating activities 25,492 20,642 22,905 19,058 Cash flows from investing activities Interest received 159 63 159 63 Purchase of intangible assets (3,112) (3,906) (3,112) (3,906) Purchase of PPE and investment property (29,266) (14,239) (29,266) (14,239) Sales of PPE and investment property 114 18,940 114 18,940 Receipt of cash donations to purchase assets - 24 1,794 735 Net cash flows used in investing activities (32,105) 882 (30,311) 1,593 Cash flows from financing activities Public dividend capital received 2,224 4,762 2,224 4,762 Movement on loans from DHSC (2,958) (3,595) (2,958) (3,595) Capital element of finance lease rental payments (311) (8) (311) (8) Interest on loans (287) (367) (287) (367) Interest paid on finance lease liabilities (15) (6) (15) (6) PDC dividend paid (5,213) (5,150) (5,213) (5,150) Net cash flows used in financing activities (6,560) (4,364) (6,560) (4,364) Increase / (decrease) in cash and cash equivalents (13,173) 17,160 (13,966) 16,287 Cash and cash equivalents at 1 April - brought forward 35,504 18,344 32,912 16,625 Cash and cash equivalents at 31 March 24 22,331 35,504 18,946 32,912
191 Notes to the Accounts
Note 1 Accounting policies and other information
Note 1.1 Basis of preparation
NHS Improvement, in exercising the statutory functions conferred on Monitor, has directed that the financial statements of the Trust shall meet the accounting requirements of the Department of Health and Social Care Group Accounting Manual (GAM), which shall be agreed with HM Treasury. Consequently, the following financial statements have been prepared in accordance with the GAM 2018/19 issued by the Department of Health and Social Care. The accounting policies contained in the GAM follow International Financial Reporting Standards to the extent that they are meaningful and appropriate to the NHS, as determined by HM Treasury, which is advised by the Financial Reporting Advisory Board. Where the GAM permits a choice of accounting policy, the accounting policy that is judged to be most appropriate to the particular circumstances of the Trust for the purpose of giving a true and fair view has been selected. The particular policies adopted are described below. These have been applied consistently in dealing with items considered material in relation to the accounts.
Note 1.1.1 Accounting convention These accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, and certain financial assets and financial liabilities.
Note 1.2 Going concern
These accounts have been prepared on a going concern basis.
Whilst the Trust does not consider itself to be significantly exposed to any significant risks arising from the EU exit, the ongoing uncertainty of a final agreed outcome means that this cannot be fully assessed. The potential areas of exposure are wide ranging across the accounts. Income and expenditure may be affected by issues such as increased supply chain, fuel and drug costs. Whilst the Balance Sheet may be affected by ability of debtors to meet debts due to the Trust, and fluctuating property valuations.
The Trust continues to operate in a climate of financial uncertainly within the NHS in England. Whilst there are known risks over the coming five years, including a substantial capital programme, continuing operational pressures and financial challenges, there is sufficient evidence to support the strong likelihood the Trust will continue operating over the next Financial Year.
The key pieces of evidence in support of this is the balanced financial plan for 2019/20 which has been approved by the Trust Board of Directors and submitted to NHSI for review and an internal 5 year financial strategy that demonstrates the expectation of balanced budgets over the next 5 years.
The Board of Directors has a reasonable expectation that the Trust will have access to adequate resources to continue to deliver the full range of mandatory services for the foreseeable future. The assessment accords with the statutory guidance contained in the NHS Foundation Trust Annual Reporting Manual and the Department of Health Group Accounting Manual and for this reason the Trust continues to adopt the going concern basis in preparing the accounts.
Note 1.3 Consolidation
192 NHS Charitable Funds The Trust is the corporate trustee to RUH Charitable Fund. The Trust has assessed its relationship to the charitable fund and determined it to be a subsidiary because the Trust is exposed to, or has rights to, variable returns and other benefits for itself, patients and staff from its involvement with the Charitable Fund and has the ability to affect those returns and other benefits through it's relationship with the fund.
The Charitable Fund’s statutory accounts are prepared to 31 March in accordance with the UK Charities Statement of Recommended Practice (SORP) which is based on UK Financial Reporting Standard (FRS) 102. On consolidation, necessary adjustments are made to the charity’s assets, liabilities and transactions to:
• recognise and measure them in accordance with the Trust's accounting policies and • eliminate intra-group transactions, balances, gains and losses.
The key accounting policy for the RUH Charitable Funds relates to it's investments. The Corporate Trustee have established a policy under which the funds are invested, ensuring that the money is not exposed to undue risk but provides returns sufficient to counter the effects of inflation. All investments are held at market value on the balance sheet.
Joint ventures The Trust has a one third controlling interest in Wiltshire Health and Care LLP, in partnership with Salisbury NHS Foundation Trust and Great Western Hospitals NHS Foundation Trust.
The LLP has a separate Board but strategic control of the organisation remains with the partners as detailed in the Members Agreement signed by the three NHS Foundation Trusts.
The financial risks of the LLP to the Members are limited to nil as per the signed members agreement, the surpluses are accounted for in the Trust's accounts using the equity method, however as the LLP reports a breakeven position as at the 31st March 2019 there is no investment gain to recognise within the Trust's financial position.
193 Note 1.4 Revenue Note 1.4.1 Revenue from contracts with customers Where income is derived from contracts with customers, it is accounted for under IFRS 15. The GAM expands the definition of a contract to include legislation and regulations which enables an entity to receive cash or another financial asset that is not classified as a tax by the Office of National Statistics (ONS). As directed by the GAM, the transition to IFRS 15 in 2018/19 has been completed in accordance with paragraph C3 (b) of the Standard: applying the Standard retrospectively but recognising the cumulative effects at the date of initial application (1 April 2018).
Revenue in respect of goods/services provided is recognised when (or as) performance obligations are satisfied by transferring promised goods/services to the customer and is measured at the amount of the transaction price allocated to those performance obligations. At the year end, the Trust accrues income relating to performance obligations satisfied in that year. Where the Trust’s entitlement to consideration for those goods or services is unconditional a contract receivable will be recognised. Where entitlement to consideration is conditional on a further factor other than the passage of time, a contract asset will be recognised. Where consideration received or receivable relates to a performance obligation that is to be satisfied in a future period, the income is deferred and recognised as a contract liability.
Revenue from NHS contracts The main source of income for the Trust is contracts with commissioners for health care services. A performance obligation relating to delivery of a spell of health care is generally satisfied over time as healthcare is received and consumed simultaneously by the customer as the Trust performs it. The customer in such a contract is the commissioner, but the customer benefits as services are provided to their patient. Even where a contract could be broken down into separate performance obligations, healthcare generally aligns with paragraph 22(b) of the Standard entailing a delivery of a series of goods or services that are substantially the same and have a similar pattern of transfer. At the year end, the Trust accrues income relating to activity delivered in that year, where a patient care spell is incomplete. Similarly, where pathway payments have been received in year but activity is not yet complete, the Trust defers partial income relating to the incomplete pathway. The payment terms for all income received under NHS contracts do not deviate from the standard payment terms, as set out S36 of the 2018/19 NHS standard contract guidance. The contracts in place with Commissioners do not specify specific Commissioner requested services.
Revenue is recognised to the extent that collection of consideration is probable. Where contract challenges from commissioners are expected to be upheld, the Trust reflects this in the transaction price and derecognises the relevant portion of income. Where the Trust is aware of a penalty based on contractual performance, the Trust reflects this in the transaction price for its recognition of revenue. Revenue is reduced by the value of the penalty. The effect of readmissions is material however is reflected in the contract baseline and therefore in the transaction price. The Trust receives income from Commissioners under Commissioning for Quality and Innovation (CQUIN) schemes. The Trust agrees schemes with Commissioners however the CQUIN payments are not considered distinct performance obligations in their own right; instead they form part of the transaction price for performance obligations under the contract. The Trust has undertaken an assessment of all revenue streams as required by IFRS 15 - Revenue from contracts with Customers. The Trust was already treating all material revenue streams in line with the requirements set out under the standard, and did not identify any significant amendments to the treatment of revenue for 2018/19.
Revenue from research contracts Where research contracts fall under IFRS 15, revenue is recognised as and when performance obligations are satisfied. For some contracts, the assessment shows that the revenue project constitutes one performance obligation over the course of the multi-year contract. In these cases the assessment shows that the Trust’s interim performance does not create an asset with alternative use for the Trust, and the Trust has an enforceable right to payment for the performance completed to date. It is therefore considered that the performance obligation is satisfied over time, and the Trust recognises revenue each year over the course of the contract.
194 NHS injury cost recovery scheme The Trust receives income under the NHS injury cost recovery scheme, designed to reclaim the cost of treating injured individuals to whom personal injury compensation has subsequently been paid, for instance by an insurer. The Trust recognises the income when it receives notification from the Department of Work and Pension's Compensation Recovery Unit, has completed the NHS2 form and confirmed there are no discrepancies with the treatment. The income is measured at the agreed tariff for the treatments provided to the injured individual, less an allowance for unsuccessful compensation claims and doubtful debts in line with IFRS 9 requirements of measuring expected credit losses over the lifetime of the asset. For 2018/19, the Compensation Recovery Unit (CRU) has advised the percentage probability of not receiving the income is 21.89%
Note 1.4.2 Revenue grants and other contributions to expenditure Government grants are grants from government bodies other than income from Commissioners or Trusts for the provision of services. Where a grant is used to fund revenue expenditure it is taken to the Statement of Comprehensive Income to match that expenditure.
The value of the benefit received when accessing funds from the Government's apprenticeship service is recognised as income at the point of receipt of the training service. Where these funds are paid directly to an accredited training provider, the corresponding notional expense is also recognised at the point of recognition for the benefit.
Note 1.5 Expenditure on employee benefits
Short-term employee benefits Salaries, wages and employment-related payments such as social security costs and the apprenticeship levy are recognised in the period in which the service is received from employees.
Pension costs
NHS Pension Scheme Past and present employees are covered by the provisions of the NHS Pension Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, general practices and other bodies, allowed under the direction of Secretary of State, in England and Wales. The scheme is not designed in a way that would enable employers to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as though it is a defined contribution scheme.
Employer's pension cost contributions are charged to operating expenses as and when they become due.
Additional pension liabilities arising from early retirements are not funded by the scheme except where the retirement is due to ill-health. The full amount of the liability for the additional costs is charged to the operating expenses at the time the trust commits itself to the retirement, regardless of the method of payment.
Note 1.6 Expenditure on other goods and services
Expenditure on goods and services is recognised when, and to the extent that they have been received, and is measured at the fair value of those goods and services. Expenditure is recognised in operating expenses except where it results in the creation of a non-current asset such as property, plant and equipment.
195 Note 1.7 Property, plant and equipment
Note 1.7.1 Recognition
Property, plant and equipment is capitalised where:
• it is held for use in delivering services or for administrative purposes • it is probable that future economic benefits will flow to, or service potential be provided to, the Trust • it is expected to be used for more than one financial year • the cost of the item can be measured reliably • the item has cost of at least £5,000, or • collectively, a number of items have a cost of at least £5,000 and individually have cost of more than £250, where the assets are functionally interdependent, had broadly simultaneous purchase dates, are anticipated to have similar disposal dates and are under single managerial control.
Where a large asset, for example a building, includes a number of components with significantly different asset lives, e.g. plant and equipment, then these components are treated as separate assets and depreciated over their own useful lives.
Note 1.7.2 Measurement Valuation All property, plant and equipment assets are measured initially at cost, representing the costs directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management.
Land, buildings and dwellings are measured subsequently at valuation. Assets which are held for their service potential and are in use (i.e. operational assets used to deliver either front line services or back office functions) are measured at their current value in existing use. Assets that were most recently held for their service potential but are surplus with no plan to bring them back into use are measured at fair value where there are no restrictions on sale at the reporting date and where they do not meet the definitions of investment properties or assets held for sale.
Revaluations of land, buildings and dwellings are performed with sufficient regularity to ensure that carrying values are not materially different from those that would be determined at the end of the reporting period. The Trust obtained a desktop revaluation of its land, buildings and dwellings as at 31st March 2019. The current values in existing use are determined as follows: • Non-specialised buildings – market value for existing use • Specialised buildings – depreciated replacement cost on a modern equivalent asset basis. • Land - market value for existing use or depreciated replacement cost on a modern equivalent asset basis.
Properties in the course of construction for service or administration purposes are carried at cost, less any impairment loss. The cost includes any associated professional fees and, where capitalised in accordance with IAS 23, borrowings costs. Assets are revalued and depreciation commences when the assets are brought into use.
IT equipment, transport equipment, furniture and fittings, and plant and machinery that are held for operational use are valued at depreciated historic cost where these assets have short useful lives or low values or both, as this is not considered to be materially different from current value in existing use.
196 Subsequent expenditure Subsequent expenditure relating to an item of property, plant and equipment is recognised as an increase in the carrying amount of the asset when it is probable that additional future economic benefits or service potential deriving from the cost incurred to replace a component of such item will flow to the enterprise and the cost of the item can be determined reliably. Where a component of an asset is replaced, the cost of the replacement is capitalised if it meets the criteria for recognition above. The carrying amount of the part replaced is de-recognised. Other expenditure that does not generate additional future economic benefits or service potential, such as repairs and maintenance, is charged to the Statement of Comprehensive Income in the period in which it is incurred. Depreciation Items of property, plant and equipment are depreciated over their remaining useful lives in a manner consistent with the consumption of economic or service delivery benefits. Depreciation is calculated on a straight line basis. Freehold land is considered to have an infinite life and is not depreciated.
Property, plant and equipment which has been reclassified as ‘held for sale’ cease to be depreciated upon the reclassification. Assets in the course of construction are not depreciated until the asset is brought into use or reverts to the Trust, respectively.
Revaluation gains and losses Revaluation gains are recognised in the revaluation reserve, except where, and to the extent that, they reverse a revaluation decrease that has previously been recognised in operating expenses, in which case they are recognised in operating income.
Revaluation losses are charged to the revaluation reserve to the extent that there is an available balance for the asset concerned, and thereafter are charged to operating expenses.
Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item of ‘other comprehensive income’. In accordance with the GAM, impairments that arise from a clear consumption of economic benefits or of service potential in the asset are charged to operating expenses. A compensating transfer is made from the revaluation reserve to the income and expenditure reserve of an amount equal to the lower of (i) the impairment charged to operating expenses; and (ii) the balance in the revaluation reserve attributable to that asset before the impairment.
An impairment that arises from a clear consumption of economic benefit or of service potential is reversed when, and to the extent that, the circumstances that gave rise to the loss is reversed. Reversals are recognised in operating expenditure to the extent that the asset is restored to the carrying amount it would have had if the impairment had never been recognised. Any remaining reversal is recognised in the revaluation reserve. Where, at the time of the original impairment, a transfer was made from the revaluation reserve to the income and expenditure reserve, an amount is transferred back to the revaluation reserve when the impairment reversal is recognised.
Other impairments are treated as revaluation losses. Reversals of ‘other impairments’ are treated as revaluation gains.
Note 1.7.3 De-recognition Assets intended for disposal are reclassified as ‘held for sale’ once all of the following criteria are met: • the asset is available for immediate sale in its present condition subject only to terms which are usual and customary for such sales; • the sale must be highly probable i.e.: - management are committed to a plan to sell the asset - an active programme has begun to find a buyer and complete the sale - the asset is being actively marketed at a reasonable price - the sale is expected to be completed within 12 months of the date of classification as ‘held for sale’ and - the actions needed to complete the plan indicate it is unlikely that the plan will be abandoned or significant changes made to it.
197 Following reclassification, the assets are measured at the lower of their existing carrying amount and their ‘fair value less costs to sell’. Depreciation ceases to be charged. Assets are de-recognised when all material sale contract conditions have been met.
Property, plant and equipment which is to be scrapped or demolished does not qualify for recognition as ‘held for sale’ and instead is retained as an operational asset and the asset’s useful life is adjusted. The asset is de-recognised when scrapping or demolition occurs.
Note 1.7.4 Donated and grant funded assets
Donated and grant funded property, plant and equipment assets are capitalised at their fair value on receipt. The donation/grant is credited to income at the same time, unless the donor has imposed a condition that the future economic benefits embodied in the grant are to be consumed in a manner specified by the donor, in which case, the donation/grant is deferred within liabilities and is carried forward to future financial years to the extent that the condition has not yet been met.
The donated and grant funded assets are subsequently accounted for in the same manner as other items of property, plant and equipment.
198 Note 1.7.5 Useful lives of property, plant and equipment Useful lives reflect the total life of an asset and not the remaining life of an asset. The range of useful lives are shown in the table below: Min life Max life Years Years Land 70 70 Buildings, excluding dwellings 2 60 Dwellings 37 39 Plant & machinery 2 25 Transport equipment 5 7 Information technology 2 7 Furniture & fittings 2 15
Finance-leased assets (including land) are depreciated over the shorter of the useful life or the lease term, unless the Trust expects to acquire the asset at the end of the lease term in which case the assets are depreciated in the same manner as owned assets above.
Note 1.8 Intangible assets
Note 1.8.1 Recognition Intangible assets are non-monetary assets without physical substance which are capable of being sold separately from the rest of the Trust’s business or which arise from contractual or other legal rights. They are recognised only where it is probable that future economic benefits will flow to, or service potential be provided to, the Trust and where the cost of the asset can be measured reliably.
Internally generated goodwill, brands, mastheads, publishing titles, customer lists and similar items are not capitalised as intangible assets.
Expenditure on research is not capitalised.
Expenditure on development is capitalised only where all of the following can be demonstrated:
• the project is technically feasible to the point of completion and will result in an intangible asset for sale or use • the Trust intends to complete the asset and sell or use it • the Trust has the ability to sell or use the asset • how the intangible asset will generate probable future economic or service delivery benefits, e.g., the presence of a market for it or its output, or where it is to be used for internal use, the usefulness of the asset; • adequate financial, technical and other resources are available to the trust to complete the development and sell or use the asset and • the Trust can measure reliably the expenses attributable to the asset during development.
Software which is integral to the operation of hardware, e.g. an operating system, is capitalised as part of the relevant item of property, plant and equipment. Software which is not integral to the operation of Note 1.8.2 Measurement
199 Intangible assets are recognised initially at cost, comprising all directly attributable costs needed to create, produce and prepare the asset to the point that it is capable of operating in the manner intended by management.
Subsequently intangible assets are measured at current value in existing use. Where no active market exists, intangible assets are valued at the lower of depreciated replacement cost and the value in use where the asset is income generating. Revaluations gains and losses and impairments are treated in the same manner as for property, plant and equipment. An intangible asset which is surplus with no plan to bring it back into use is valued at fair value under IFRS 13, if it does not meet the requirements of IAS 40 of IFRS 5.
Intangible assets held for sale are measured at the lower of their carrying amount or “fair value less costs to sell”. Amortisation Intangible assets are amortised over their expected useful lives in a manner consistent with the consumption of economic or service delivery benefits.
Note 1.8.3 Useful economic life of intangible assets
Useful lives reflect the total life of an asset and not the remaining life of an asset. The range of useful lives Min life Max life Years Years
Software licences 2 5 Licences & trademarks 2 9
200 Note 1.9 Inventories Inventories are valued at the lower of cost and net realisable value. The cost of inventories is measured using the first in, first out (FIFO) method.
Note 1.10 Cash and cash equivalents Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value.
In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand and that form an integral part of the Trust’s cash management. Cash, bank and overdraft balances are recorded at current values.
Note 1.11 Financial assets and financial liabilities
Note 1.11.1 Recognition Financial assets and financial liabilities arise where the Trust is party to the contractual provisions of a financial instrument, and as a result has a legal right to receive or a legal obligation to pay cash or another financial instrument. The GAM expands the definition of a contract to include legislation and regulations which give rise to arrangements that in all other respects would be a financial instrument and do not give rise to transactions classified as a tax by ONS.
This includes the purchase or sale of non-financial items (such as goods or services), which are entered into in accordance with the Trust’s normal purchase, sale or usage requirements and are recognised when, and to the extent which, performance occurs, i.e., when receipt or delivery of the goods or services is made.
Note 1.11.2 Classification and measurement Financial assets and financial liabilities are initially measured at fair value plus or minus directly attributable transaction costs except where the asset or liability is not measured at fair value through income and expenditure. Fair value is taken as the transaction price, or otherwise determined by reference to quoted market prices or valuation techniques.
Financial assets or financial liabilities in respect of assets acquired or disposed of through finance leases are recognised and measured in accordance with the accounting policy for leases described below.
Financial assets are classified as subsequently measured at amortised cost, fair value through income and expenditure or fair value through other comprehensive income. Financial liabilities classified as subsequently measured at amortised cost or fair value through income and expenditure.
Financial assets and financial liabilities at amortised cost Financial assets and financial liabilities at amortised cost are those held with the objective of collecting contractual cash flows and where cash flows are solely payments of principal and interest. This includes cash equivalents, contract and other receivables, trade and other payables, rights and obligations under lease arrangements and loans receivable and payable.
After initial recognition, these financial assets and financial liabilities are measured at amortised cost using the effective interest method less any impairment (for financial assets). The effective interest rate is the rate that exactly discounts estimated future cash payments or receipts through the expected life of the financial asset or financial liability to the gross carrying amount of a financial asset or to the amortised cost of a financial liability.
Interest revenue or expense is calculated by applying the effective interest rate to the gross carrying amount of a financial asset or amortised cost of a financial liability and recognised in the Statement of Comprehensive Income and a financing income or expense. In the case of loans held from the Department of Health and Social Care, the effective interest rate is the nominal rate of interest charged on the loan.
201 Financial assets measured at fair value through other comprehensive income A financial asset is measured at fair value through other comprehensive income where business model objectives are met by both collecting contractual cash flows and selling financial assets and where the cash flows are solely payments of principal and interest. Movements in the fair value of financial assets in this category are recognised as gains or losses in other comprehensive income except for impairment losses. On derecognition, cumulative gains and losses previously recognised in other comprehensive income are reclassified from equity to income and expenditure, except where the Trust elected to measure an equity instrument in this category on initial recognition.
The Trust has irrevocably elected to measure the following equity instruments at fair value through other comprehensive income. All gains and losses arising from investment funds held by The Royal United Charitable Fund will be measured at fair value through Other Comprehensive Income. The investment fund does not meet the criteria set out in the accounting standards to be recognised as a gain or loss through income and expenditure.
Impairment of financial assets For all financial assets measured at amortised cost including lease receivables, contract receivables and contract assets or assets measured at fair value through other comprehensive income, the Trust recognises an allowance for expected credit losses.
The Trust adopts the simplified approach to impairment for contract and other receivables, contract assets and lease receivables, measuring expected losses as at an amount equal to lifetime expected losses. For other financial assets, the loss allowance is initially measured at an amount equal to 12-month expected credit losses (stage 1) and subsequently at an amount equal to lifetime expected credit losses if the credit risk assessed for the financial asset significantly increases (stage 2).
In line with NHS guidance, the Trust has not applied an expected credit loss to NHS debts as they are deemed recoverable within the NHS group.
For financial assets that have become credit impaired since initial recognition (stage 3), expected credit losses at the reporting date are measured as the difference between the asset’s gross carrying amount and the present value of estimated future cash flows discounted at the financial asset’s original effective interest rate.
Expected losses are charged to operating expenditure within the Statement of Comprehensive Income and reduce the net carrying value of the financial asset in the Statement of Financial Position.
Note 1.11.3 Derecognition
Financial assets are de-recognised when the contractual rights to receive cash flows from the assets have expired or the Trust has transferred substantially all the risks and rewards of ownership.
Financial liabilities are de-recognised when the obligation is discharged, cancelled or expires.
202 Note 1.12 Leases Leases are classified as finance leases when substantially all the risks and rewards of ownership are transferred the lessee. All other leases are classified as operating leases.
Note 1.12.1 The Trust as lessee
Finance leases Where substantially all risks and rewards of ownership of a leased asset are borne by the Trust, the asset is recorded as property, plant and equipment and a corresponding liability is recorded. The value at which both are recognised is the lower of the fair value of the asset or the present value of the minimum lease payments, discounted using the interest rate implicit in the lease.
The asset and liability are recognised at the commencement of the lease. Thereafter the asset is accounted for a item of property plant and equipment.
The annual rental charge is split between the repayment of the liability and a finance cost so as to achieve a constant rate of finance over the life of the lease. The annual finance cost is charged to Finance Costs in the Statement of Comprehensive Income. The lease liability, is de-recognised when the liability is discharged, cancelled or expires. Operating leases Operating lease payments are recognised as an expense on a straight-line basis over the lease term. Lease incentives are recognised initially as a liability and subsequently as a reduction of rentals on a straight-line basis over the lease term.
Contingent rentals are recognised as an expense in the period in which they are incurred.
Leases of land and buildings Where a lease is for land and buildings, the land component is separated from the building component and the classification for each is assessed separately.
Note 1.13 Provisions The Trust recognises a provision where it has a present legal or constructive obligation of uncertain timing or amount; for which it is probable that there will be a future outflow of cash or other resources; and a reliable estim can be made of the amount. The amount recognised in the Statement of Financial Position is the best estimate o the resources required to settle the obligation. Where the effect of the time value of money is significant, the estimated risk-adjusted cash flows are discounted using the discount rates published and mandated by HM Treasury.
Clinical negligence costs NHS Resolution operates a risk pooling scheme under which the Trust pays an annual contribution to NHS Resolution, which, in return, settles all clinical negligence claims. Although NHS Resolution is administratively responsible for all clinical negligence cases, the legal liability remains with the Trust. The total value of clinical negligence provisions carried by NHS Resolution on behalf of the Trust is disclosed at note 29 but is not recogni in the Trust’s accounts.
Non-clinical risk pooling The Trust participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are ris pooling schemes under which the Trust pays an annual contribution to NHS Resolution and in return receives assistance with the costs of claims arising. The annual membership contributions, and any “excesses” payable in respect of particular claims are charged to operating expenses when the liability arises.
203 Note 1.14 Contingencies
Contingent assets (that is, assets arising from past events whose existence will only be confirmed by one or mor events not wholly within the entity’s control) are not recognised as assets, but are disclosed in note 30 where an economic benefits is probable. Contingent liabilities are not recognised, but are disclosed in note 30, unless the probability of a transfer of econo is remote.
Contingent liabilities are defined as:
• possible obligations arising from past events whose existence will be confirmed only by the occurrence of one o uncertain future events not wholly within the entity’s control; or
• present obligations arising from past events but for which it is not probable that a transfer of economic benefits for which the amount of the obligation cannot be measured with sufficient reliability.
Note 1.15 Public dividend capital
Public dividend capital (PDC) is a type of public sector equity finance based on the excess of assets over liabilitie of establishment of the predecessor NHS organisation. HM Treasury has determined that PDC is not a financial within the meaning of IAS 32.
At any time, the Secretary of State can issue new PDC to, and require repayments of PDC from, the Trust. PDC at the value received.
A charge, reflecting the cost of capital utilised by the Trust, is payable as public dividend capital dividend. The ch calculated at the rate set by HM Treasury (currently 3.5%) on the average relevant net assets of the trust during year. Relevant net assets are calculated as the value of all assets less the value of all liabilities, except for (i) donated assets (including lottery funded assets), (ii) average daily cash balances held with the Government Banking Services (GBS) and National Loans Fund (N excluding cash balances held in GBS accounts that relate to a short-term working capital facility, and (iii) any PDC dividend balance receivable or payable.
In accordance with the requirements laid down by the Department of Health and Social Care (as the issuer of PD dividend for the year is calculated on the actual average relevant net assets as set out in the “pre-audit” version o accounts. The dividend thus calculated is not revised should any adjustment to net assets occur as a result the a annual accounts.
Note 1.16 Value added tax
Most of the activities of the Trust are outside the scope of VAT and, in general, output tax does not apply and inp purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in th purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated n
204 Note 1.17 Third party assets
Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts s has no beneficial interest in them. However, they are disclosed in a separate note to the accounts in accordance requirements of HM Treasury’s FREM.
Note 1.18 Losses and special payments
Losses and special payments are items that Parliament would not have contemplated when it agreed funds for th service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subj control procedures compared with the generality of payments. They are divided into different categories, which g way that individual cases are handled. Losses and special payments are charged to the relevant functional head expenditure on an accruals basis, including losses which would have been made good through insurance cover not been bearing their own risks (with insurance premiums then being included as normal revenue expenditure).
However the losses and special payments note is compiled directly from the losses and compensations register on an accrual basis with the exception of provisions for future losses.
205 Note 1.19 Critical judgements in applying accounting policies
In the application of the Trust’s accounting policies, management is required to make judgments, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from sources. The estimates and associated assumptions are based on historical experience and other factors that ar to be relevant. Actual results may differ from those estimates and the estimates and underlying assumptions are reviewed. Revisions to accounting estimates are recognised in the period in which the estimate is revised if the r affects only that period or in the period of the revision and future periods if the revision affects both current and fu
Property Valuations Property, plant and dwellings were valued by Cushman and Wakefield as at 31 March 2019. These valuations a the Royal Institution of Chartered Surveyors valuation standards insofar as these are consistent with the requirem Treasury, the National Health Service and the Department of Health. Property valuation techniques include an in element of estimation; in particular specialised assets that have no active market require valuation based on ass likely replacement cost of an asset. Future property values will be influenced by factors such as construction cos developments in healthcare technology and any recognised impairments. Future asset values will inevitably fluc Trust mitigates against material correcting adjustments by commissioning regular professional asset valuation re Accounting policy note 1.7 provides further detail on the Trust’s asset valuation accounting policy.
Note 1.20 Sources of estimation uncertainty
The following are assumptions about the future and other major sources of estimation uncertainty that have a sig of resulting in a material adjustment to the carrying amounts of assets and liabilities within the next financial year
Estimation of asset lives as the basis of deprecation calculations Depreciation of equipment is based on asset lives, which have been estimated on recognition of assets.
Provisions Provisions have been made for probable legal and constructive obligations of uncertain timing or amount as at th date. These are based on estimates using information available at the reporting date. They are estimates of futur which are dependent on future events. Any difference between these estimates and the actual future liability will accounted for in the period in which such determination is made. Details of the Trust's provisions are set out in n
Note 1.21 Early adoption of standards, amendments and interpretations No new accounting standards or revisions to existing standards have been early adopted in 2018/19.
Note 1.22 Standards, amendments and interpretations in issue but not yet effective or adopted
The following standards, amendments and interpretations have been issued by the International Accounting Stan (IASB) and International Financial Reporting Interpretations Committee (IFRIC) but have not yet been adopted in Reporting Manual. NHS Improvement does not permit the early adoption of accounting standards, amendments interpretations that are in issue at the reporting date but effective at a subsequent reporting period.
IFRS 16 Leases – Application required for accounting periods beginning on or after 1 April 2020. IFRS 17 Insurance Contracts - Application required for accounting periods beginning on or after 1 January 2021 adopted by the FReM: early adoption is not therefore permitted IFRIC 23 Uncertainty over Income Tax Treatments – Application required for accounting periods beginning on or January 2019. The Trust await the interpretation for the public sector and NHS before interpreting the effect on the accounts.
206 Note 2 Operating Segments
The Trust Board is the Chief Operating Decision Maker. The Trust Board reviews and has a strategic overview of the Trust's healthcare services, and all operating segments.
The Trust consider the RUH Charitable Funds to be an operating segment. The Trustees of the RUH Charitable Funds are Corporate Trustees of the Trust Board. Whilst the RUH Charitable Funds is managed by, and operates separately from, the main services provided by the Trust, the Trust Board receives quarterly performance reports from the Charity.
Income for the RUH Charitable Funds comprises of donations mainly from individuals and local organisations. The activities of the Charity are focussed to improve the environment in the hospital for staff and patients and support innovative developments not funded by NHS money.
The Charitable Fund does not own any Property, Plant & Equipment or Intangible assets. Income, expenditure, assets and liabilities of the Charity are not reported by segment to the Trust Board, rather aggregated as part of the whole organisation to Management Board and the Board of Directors.
The financial position of the Charity is reported within this set of Financial Statements and as such has not been seperately disclosed below.
207 Note 3 Operating income from patient care activities (Group) All income from patient care activities relates to contract income recognised in line with accounting policy 1.4.1
Note 3.1 Income from patient care activities (by nature) 2018/19 2017/18 £000 £000 Elective income 39,905 38,566 Non elective income 115,818 110,696 First outpatient income 36,092 34,277 Follow up outpatient income 30,826 28,353 A & E income 12,385 10,882 High cost drugs income from commissioners (excluding pass-through costs) 34,165 33,524 Other NHS clinical income 27,879 22,057 Private patient income 645 623 Agenda for Change pay award central funding 3,248 - Other clinical income 5,470 3,749 Total income from activities 306,433 282,727
Note 3.2 Income from patient care activities (by source) 2018/19 2017/18 Income from patient care activities received from: £000 £000 NHS England 52,497 50,534 Clinical commissioning groups 243,350 226,624 Department of Health and Social Care 3,261 - Other NHS providers 176 314 NHS other 1,349 483 Local authorities 1,251 846 Non-NHS: private patients 645 623 Non-NHS: overseas patients (chargeable to patient) 295 152 Injury cost recover scheme 603 622 Non NHS: other 3,006 2,529 Total income from activities 306,433 282,727 Of which: Related to continuing operations 306,433 282,727 Related to discontinued operations - -
208 Note 3.3 Overseas visitors (relating to patients charged directly by the provider) 2018/19 2017/18 £000 £000 Income recognised this year 295 152 Cash payments received in-year 185 46 Amounts added to provision for impairment of receivables - 51
Note 4 Other operating income (Group) 2018/19 2017/18 £000 £000 Other operating income from contracts with customers: Research and development (contract) 1,064 955 Education and training (excluding notional apprenticeship levy income) 14,212 12,833 Non-patient care services to other bodies 7,992 8,596 Provider sustainability / sustainability and transformation fund income (PSF / 14,851 11,366 Income in respect of employee benefits accounted on a gross basis 2,478 1,765 Other contract income 5,000 4,986 Other non-contract operating income: Education and training - notional income from apprenticeship fund - 77 Receipt of capital grants and donations 1,964 24 Rental revenue from operating leases 270 486 Charitable fund incoming resources 1,555 3,291 Total other operating income 49,386 44,379 Of which: Related to continuing operations 49,386 44,379 Related to discontinued operations - -
Note 4.1 Income from activities arising from commissioner requested services
Under the terms of its provider licence, the Trust is required to analyse the level of income from activities that has arisen from commissioner requested and non-commissioner requested services. Commissioner requested services are defined in the provider licence and are services that commissioners believe would need to be protected in the event of provider failure. This information is provided in the table below:
2018/19 2017/18 £000 £000 Income from services designated as commissioner requested services 297,070 278,355 Income from services not designated as commissioner requested services 58,749 48,751 Total 355,819 327,106
209 Note 5 Operating expenses (Group) 2018/19 2017/18 £000 £000 Purchase of healthcare from NHS and DHSC bodies 17 - Purchase of healthcare from non-NHS and non-DHSC bodies 1,272 1,486 Staff and executive directors costs 207,750 196,766 Remuneration of non-executive directors 149 150 Supplies and services - clinical (excluding drugs costs) 33,313 33,531 Supplies and services - general 3,890 3,824 drugs) 42,997 42,642 Inventories written down - 58 Consultancy costs 921 413 Establishment 3,455 2,837 Premises 10,339 10,242 Transport (including patient travel) 1,012 836 Depreciation on property, plant and equipment 8,517 7,635 Amortisation on intangible assets 1,736 1,044 Net impairments 1,844 (1,853) Movement in credit loss allowance: contract receivables / contract assets (180) - Movement in credit loss allowance: all other receivables and investments - 277 Increase/(decrease) in other provisions (1,248) 145 Audit fees payable to the external auditor audit services- statutory audit 54 61 other auditor remuneration (external auditor only) 11 11 Internal audit costs 110 105 Clinical negligence 10,000 7,423 Legal fees 209 989 Insurance 333 243 Research and development 2,697 2,455 Education and training 3,057 3,647 Rentals under operating leases 18 69 Redundancy - 72 Hospitality 245 220 Losses, ex gratia & special payments 13 49 Other NHS charitable fund resources expended 744 753 Other 402 437 Total 333,677 316,567 Of which: Related to continuing operations 333,677 316,567 Related to discontinued operations - -
210 Note 6 Other auditor remuneration (Group) 2018/19 2017/18 £000 £000 Other auditor remuneration paid to the external auditor: Audit-related assurance services 11 11 Total 11 11
Note 6.1 Limitation on auditor's liability (Group) The limitation on auditor's liability for external audit work is £1m (2017/18: £1m).
Note 7 Impairment of assets (Group) 2018/19 2017/18 £000 £000 Net impairments charged to operating surplus / deficit resulting from: Changes in market price 1,844 (801) Other - (1,052) Total net impairments charged to operating surplus / deficit 1,844 (1,853) Impairments charged to the revaluation reserve - - Total net impairments 1,844 (1,853)
211 Note 8 Employee benefits (Group) 2018/19 2017/18 Total Total £000 £000 Salaries and wages 170,529 162,513 Social security costs 16,608 15,932 Apprenticeship levy 839 794 Employer's contributions to NHS pensions 20,329 19,445 Temporary staff (including agency) 4,487 3,684 NHS charitable funds staff 536 468 Total gross staff costs 213,328 202,836 Total staff costs 213,328 202,836 Of which Costs capitalised as part of assets 785 1,330
Note 9 Retirements due to ill-health (Group) During 2018/19 there were 5 early retirements from the Trust agreed on the grounds of ill-health (2 in the year ended 31 March 2018). The estimated additional pension liabilities of these ill-health retirements is £329k (£108k in 2017/18).
The cost of these ill-health retirements will be borne by the NHS Business Services Authority - Pensions Division.
212 Note 10 Pension costs
Past and present employees are covered by the provisions of the two NHS Pension Schemes. Details of the benefits payable and rules of the Schemes can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions. Both are unfunded defined benefit schemes that cover NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State in England and Wales. They are not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, each scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS body of participating in each scheme is taken as equal to the contributions payable to that scheme for the accounting period.
In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be determined at the reporting date by a formal actuarial valuation, the FReM requires that “the period between formal valuations shall be four years, with approximate assessments in intervening years”. An outline of these follows: a) Accounting valuation A valuation of scheme liability is carried out annually by the scheme actuary (currently the Government Actuary’s Department) as at the end of the reporting period. This utilises an actuarial assessment for the previous accounting period in conjunction with updated membership and financial data for the current reporting period, and is accepted as providing suitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 2019, is based on valuation data as 31 March 2018, updated to 31 March 2019 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used.
The latest assessment of the liabilities of the scheme is contained in the report of the scheme actuary, which forms part of the annual NHS Pension Scheme Accounts. These accounts can be viewed on the NHS Pensions website and are published annually. Copies can also be obtained from The Stationery Office.
b) Full actuarial (funding) valuation The purpose of this valuation is to assess the level of liability in respect of the benefits due under the schemes (taking into account recent demographic experience), and to recommend contribution rates payable by employees and employers.
The latest actuarial valuation undertaken for the NHS Pension Scheme was completed as at 31 March 2016. The results of this valuation set the employer contribution rate payable from April 2019. The Department of Health and Social Care have recently laid Scheme Regulations confirming that the employer contribution rate will increase to 20.6% of pensionable pay from this date.
The 2016 funding valuation was also expected to test the cost of the Scheme relative to the employer cost cap set following the 2012 valuation. Following a judgment from the Court of Appeal in December 2018 Government announced a pause to that part of the valuation process pending conclusion of the continuing legal process.
213 Note 11 Finance income (Group) Finance income represents interest received on assets and investments in the period. 2018/19 2017/18 £000 £000 Interest on bank accounts 159 63 NHS charitable fund investment income 205 151 Total finance income 364 214
Note 12 Finance expenditure (Group) Finance expenditure represents interest and other charges involved in the borrowing of money. 2018/19 2017/18 £000 £000 Interest expense: Loans from the Department of Health and Social Care 278 297 Finance leases 15 6 Total interest expense 293 303 Unwinding of discount on provisions 8 8 Total finance costs 301 311
Note 12.1 The late payment of commercial debts (interest) Act 1998 / Public Contract Regulations 2015 (Group) 2018/19 2017/18 £000 £000 Total liability accruing in year under this legislation as a result of late payments 3 -
Note 13 Other gains / (losses) (Group) 2018/19 2017/18 £000 £000 Gains on disposal of assets 3 15,338 Losses on disposal of assets (80) (97) Gains / losses on disposal of charitable fund assets - (1) Total gains / (losses) on disposal of assets (77) 15,240 Total other gains / (losses) (77) 15,240
214 Note 14 Trust income statement and statement of comprehensive income In accordance with Section 408 of the Companies Act 2006, the Trust is exempt from the requirement to present its own income statement and statement of comprehensive income. The Trust’s surplus for the period was £16.1 million (£18.6m 2017/18). The Trust's total comprehensive income for the period was £18.8 million (£20.7 million 2017/18).
215 Note 15 Intangible assets - 2018/19
Intangible Software Licences & assets under Group licences trademarks construction Total £000 £000 £000 £000 Valuation / gross cost at 1 April 2018 - brought forward 1,783 11,306 - 13,089 Additions 53 824 1,146 2,023 Disposals / derecognition (81) (94) - (175) Valuation / gross cost at 31 March 2019 1,755 12,036 1,146 14,937 forward 1,317 2,066 - 3,383 Provided during the year 159 1,577 - 1,736 Disposals / derecognition (81) (22) - (103) Amortisation at 31 March 2019 1,395 3,621 - 5,016
Net book value at 31 March 2019 360 8,415 1,146 9,921 Net book value at 1 April 2018 466 9,240 - 9,706
The Trust has only disclosed the group intangible asset note, as the RUH Charitable Funds do not own any intangible assets.
216 Note 15.1 Intangible assets - 2017/18
Intangible Software Licences & assets under Group licences trademarks construction Total £000 £000 £000 £000 Valuation / gross cost at 1 April 2017 - as previously stated 1,478 4,226 1,348 7,052 Additions 32 868 3,617 4,517 Reversals of impairments - 1,336 - 1,336 Reclassifications 276 4,876 (4,965) 187 Disposals / derecognition (3) - - (3) Valuation / gross cost at 31 March 2018 1,783 11,306 - 13,089 previously stated 1,109 949 - 2,058 Provided during the year 211 833 - 1,044 Reversals of impairments - 284 - 284 Disposals / derecognition (3) - - (3) Amortisation at 31 March 2018 1,317 2,066 - 3,383
Net book value at 31 March 2018 466 9,240 - 9,706 Net book value at 1 April 2017 369 3,277 1,348 4,994
The Trust has only disclosed the group intangible asset note, as the RUH Charitable Funds do not own any intangible assets.
217 Note 16 Property, plant and equipment - 2018/19
Buildings excluding Assets under Plant & Transport Information Furniture Group Land dwellings Dwellings construction machinery equipment technology & fittings Total £000 £000 £000 £000 £000 £000 £000 £000 £000 Valuation/gross cost at 1 April 2018 - brought forward 9,972 129,790 5,184 9,525 50,276 34 9,806 819 215,406 Additions - 4,031 40 20,591 8,266 - 997 121 34,046 Impairments - (2,734) ------(2,734) Reversals of impairments 890 ------890 Revaluations - (7,089) (265) - - - - - (7,354) Reclassifications - 3,549 - (3,549) - - - - - Disposals / derecognition - - - - (3,372) - (90) (16) (3,478) Valuation/gross cost at 31 March 2019 10,862 127,547 4,959 26,567 55,170 34 10,713 924 236,776
Accumulated depreciation at 1 April 2018 - brought forward - 5,010 182 - 28,409 34 5,319 343 39,297 Provided during the year - 2,842 95 - 3,869 - 1,622 89 8,517 Revaluations - (7,549) (277) - - - - - (7,826) Disposals / derecognition - - - - (3,258) - (88) (13) (3,359) Accumulated depreciation at 31 March 2019 - 303 - - 29,020 34 6,853 419 36,629
Net book value at 31 March 2019 10,862 127,244 4,959 26,567 26,150 - 3,860 505 200,147 Net book value at 1 April 2018 9,972 124,780 5,002 9,525 21,867 - 4,487 476 176,109
The Trust has only disclosed the group property, plant and equipment note, as the RUH Charitable Funds do not own any property, plant and equipment.
218 Note 16.1 Property, plant and equipment - 2017/18 Buildings excluding Assets under Plant & Transport Information Furniture Group Land dwellings Dwellings construction machinery equipment technology & fittings Total £000 £000 £000 £000 £000 £000 £000 £000 £000 Valuation / gross cost at 1 April 2017 - as previously stated 9,972 122,286 4,913 3,545 49,432 43 7,823 798 198,812 Additions - 2,807 122 7,540 4,166 - 2,168 44 16,847 Impairments - (336) ------(336) Reversals of impairments - 1,137 ------1,137 Revaluations - 2,557 149 - - - - - 2,706 Reclassifications - 1,373 - (1,560) - - - - (187) Disposals / derecognition - (34) - - (3,322) (9) (185) (23) (3,573) Valuation/gross cost at 31 March 2018 9,972 129,790 5,184 9,525 50,276 34 9,806 819 215,406
Accumulated depreciation at 1 April 2017 - as previously stated - 2,345 88 - 28,161 43 4,047 279 34,963 Provided during the year - 2,556 89 - 3,471 - 1,438 81 7,635 Revaluations - 143 5 - - - - - 148 Disposals / derecognition - (34) - - (3,223) (9) (166) (17) (3,449) Accumulated depreciation at 31 March 2018 - 5,010 182 - 28,409 34 5,319 343 39,297
Net book value at 31 March 2018 9,972 124,780 5,002 9,525 21,867 - 4,487 476 176,109 Net book value at 1 April 2017 9,972 119,941 4,825 3,545 21,271 - 3,776 519 163,849
The Trust has only disclosed the group property, plant and equipment note, as the RUH Charitable Funds do not own any property, plant and equipment.
219 Note 16.2 Property, plant and equipment financing - 2018/19
Buildings excluding Assets under Plant & Information Furniture Group Land dwellings Dwellings construction machinery technology & fittings Total £000 £000 £000 £000 £000 £000 £000 £000 Net book value at 31 March 2019 Owned - purchased 10,862 123,215 4,959 23,463 20,706 3,860 434 187,499 Finance leased - - - - 2,767 - - 2,767 Owned - donated - 4,029 - 3,104 2,677 - 71 9,881 NBV total at 31 March 2019 10,862 127,244 4,959 26,567 26,150 3,860 505 200,147
Note 16.3 Property, plant and equipment financing - 2017/18 Buildings excluding Assets under Plant & Information Furniture Group Land dwellings Dwellings construction machinery technology & fittings Total £000 £000 £000 £000 £000 £000 £000 £000 Net book value at 31 March 2018 Owned - purchased 9,972 120,830 5,002 8,154 18,233 4,487 391 167,069 Finance leased - - - - 549 - - 549 Owned - donated - 3,950 - 1,371 3,085 - 85 8,491 NBV total at 31 March 2018 9,972 124,780 5,002 9,525 21,867 4,487 476 176,109
The Trust has only disclosed the group property, plant and equipment financing note, as the RUH Charitable Funds do not own any property, plant and equipment.
220 Note 17 Donations of property, plant and equipment During the year ending 31 March 2019 the Trust received donations from which assets were purchased to the value of £1.9m.
The majority of donations were made up a follows: - £1.7m from the Royal United Hospital Bath Charitable Fund to fund project costs for RNHRD & Therapies Centre and Cancer Centre development works. - £0.2m from various sources to fund medical equipment.
The cash donation from Royal United Hospital Bath Charitable Fund was restricted to ensure funds were only used for project costs toward the RNHRD & Therapies Centre.
Note 18 Revaluations of property, plant and equipment The Trust's policy is to complete a full revaluation at least every 5 years, with a desktop review every 3 years. Cushman and Wakefield, who are a members of the Royal Institute of Chartered Surveyors and are independent of the Trust, undertook a full desktop valuation of the Trust's land and buildings as at 31 March 2019. The last full revaluation was undertaken as at 31 March 2016. The valuations were carried out in accordance with the RICS Appraisal and Valuation Manual in so far as these terms are consistent with the agreed requirements of the Department of Health and Treasury. The valuations were undertaken in accordance with the Trust's accounting policy (see note 1) and reflect the clarification in RICS guidance issued to Valuers in 2018/19. The desktop review has resulted in £472k being charged to Other Income in the Statement of Comprehensive Income. Overall, the review contributed to a net change in valuation of £1.4m and a net impairment of £1.8m. There has also been a net movement between the Revaluation Reserve and I&E Reserve of £1.9m to reflect the change in asset lives as advised by the Trust's valuers. The total movement was £2.7m reduced by £0.8m relating to in year depreciation of the Trust's revaluation reserve.
Min life Max life Useful lives of property, plant and equipment Years Years Land 70 70 Buildings, excluding dwellings 2 60 Dwellings 37 39 Plant & machinery 2 25 Transport equipment 5 7 Information technology 2 7 Furniture & fittings 2 15
221 Note 19 Other investments / financial assets (non-current) Group Trust 2018/19 2017/18 2018/19 2017/18 £000 £000 £000 £000 Carrying value at 1 April - brought forward 7,128 7,028 - - Acquisitions in year 1,193 101 - - Movement in fair value through SOCI 191 (1) - - Carrying value at 31 March 8,512 7,128 - -
The Trust does not hold any investments / financial assets as such all investments/ financial assets stated above relate to the RUH Charitable Fund.
222 Note 20 Disclosure of interests in other entities The Trust has a one third controlling interest in Wiltshire Health and Care LLP, in partnership with Salisbury NHS Foundation Trust and Great Western Hospitals NHS Foundation Trust.
Wiltshire Health and Care LLP formed in July 2016, and became responsible for the delivery of adult community healthcare across Wiltshire for at least the next five years. The LLP has a separate Board but strategic control of the organisation remains with the partners as detailed in the Members Agreement signed by the three NHS Foundation Trusts.
Wiltshire Health and Care LLP has a full year annual turnover of over £40 million. The clinical services provided to Wiltshire are procured mainly from Great Western Hospitals NHS Foundation Trust, with other small service provision, both clinical and corporate, received from Salisbury NHS Foundation Trust and the Royal United Hospitals Bath NHS Foundation Trust on a contract basis.
The financial risks of the LLP to the Members are limited to nil as per the signed members' agreement, the surpluses are accounted for in the Trust's accounts using the equity method, however the LLP reports a breakeven position as at the 31 March 2019, therefore there is no investment gain to recognise.
Note 21 Analysis of charitable fund reserves
31 March 31 March 2019 2018 £000 £000 Unrestricted funds: Unrestricted income funds 1,786 1,195 Restricted funds: Other restricted income funds 8,839 8,764 10,625 9,959
Unrestricted income funds are accumulated income funds that are expendable at the discretion of the trustees in furtherance of the charity's objects. Unrestricted funds may be earmarked or designated for specific future purposes which reduces the amount that is readily available to the charity. Restricted funds may be accumulated income funds which are expendable at the Trustee's discretion only in furtherance of the specified conditions of the donor and the objects of the charity. They may also be capital funds (e.g. endowments) where the assets are required to be invested, or retained for use rather than expended.
Note 22 Inventories Group & Trust 31 March 31 March 2019 2018 £000 £000 Drugs 422 1,774 Consumables 2,507 2,468 Energy 64 72 Other 7 8 Total inventories 3,000 4,322 of which: Held at fair value less costs to sell - -
Inventories recognised in expenses for the year were £53.8m (2017/18: £49.9m). Write-down of inventories recognised as expenses for the year were £0m (2017/18: £0.1m).
223 Note 23 Receivables Group Trust 31 March 31 March 31 March 31 March 2019 2018 2019 2018 £000 £000 £000 £000 Current Contract receivables* 30,386 - 32,180 - Trade receivables* - 9,463 - 9,463 Accrued income* - 11,168 - 11,547 Allowance for impaired contract (365) - (365) - Allowance for other impaired receivables - (512) - (512) Deposits and advances - 8 - 8 Prepayments (non-PFI) - 2,731 - 2,731 PDC dividend receivable 74 416 74 416 VAT receivable - 982 - 982 Other receivables - 106 - 106 NHS charitable funds: trade and other receivables 26 218 - - Total current receivables 30,121 24,580 31,889 24,741
Non-current Contract receivables* 1,443 - 1,443 - Trade receivables* - 1,398 - 1,398 receivables / assets* (261) - (261) - Allowance for other impaired receivables - (264) - (264) NHS charitable funds: trade and other receivables 603 400 - - Total non-current receivables 1,785 1,534 1,182 1,134
Of which receivable from NHS and DHSC group bodies: Current 20,627 11,604 20,627 12,136 Non-current - - - - *Following the application of IFRS 15 from 1 April 2018, the Trust's entitlements to consideration for work performed under contracts with customers are shown separately as contract receivables and contract assets. This replaces the previous analysis into trade receivables and accrued income. IFRS 15 is applied without restatement therefore the comparative analysis of receivables has not
224 Note 23.1 Allowances for credit losses - 2018/19 Group Trust
Contract Contract receivables receivables and contract All other and contract All other assets receivables assets receivables £000 £000 £000 £000
Allowances as at 1 Apr 2018 - brought forward 776 776 Impact of implementing IFRS 9 (and IFRS 15) on 1 April 2018 776 (776) 776 (776) Changes in existing allowances (180) - (180) - Utilisation of allowances (write offs) 30 - 30 - Allowances as at 31 Mar 2019 626 - 626 -
Note 23.3 Allowances for credit losses - 2017/18
IFRS 9 and IFRS 15 are adopted without restatement therefore this analysis is prepared in line with the requirements of IFRS 7 prior to IFRS 9 adoption. As a result it differs in format to the current period disclosure. Group Trust All All receivables receivables £000 £000
Allowances as at 1 Apr 2017 - as previously stated 909 909 Increase in provision 277 277 Amounts utilised (410) (410) Allowances as at 31 Mar 2018 776 776
225 Note 24 Cash and cash equivalents movements
Cash and cash equivalents comprise cash at bank, in hand and cash equivalents. Cash equivalents are readily convertible investments of known value which are subject to an insignificant risk of change in value. Group Trust 2018/19 2017/18 2018/19 2017/18 £000 £000 £000 £000 At 1 April 35,504 18,344 32,912 16,625 Net change in year (13,173) 17,160 (13,966) 16,287 At 31 March 22,331 35,504 18,946 32,912 Broken down into: Cash at commercial banks and in hand 38 17 14 17 Cash with the Government Banking Service 22,293 35,487 18,932 32,895 Total cash and cash equivalents as in SoFP 22,331 35,504 18,946 32,912 Total cash and cash equivalents as in SoCF 22,331 35,504 18,946 32,912
226 Note 25 Trade and other payables Group Trust 31 March 31 March 31 March 31 March 2019 2018 2019 2018 £000 £000 £000 £000 Current Trade payables 5,592 7,909 5,592 7,909 Capital payables 5,805 4,502 5,805 4,502 Accruals 9,873 9,692 9,873 9,692 VAT payables 85 78 85 78 Other taxes payable 4,192 3,985 4,192 3,985 Accrued interest on loans* - 77 - 77 Other payables 2,848 2,901 2,848 2,901 NHS charitable funds: trade and other payables 107 - - Total current trade and other payables 28,502 29,144 28,395 29,144
Of which payables from NHS and DHSC group bodies: Current 4,126 3,997 4,126 3,997 Non-current - - - -
*Following adoption of IFRS 9 on 1 April 2018, loans are measured at amortised cost. Any accrued interest is now included in the carrying value of the loan within note 26.2. IFRS 9 is applied without restatement therefore comparatives have not been restated.
Note 25.1 Early retirements in NHS payables above
There were no early retirements included in the payables note above in relation to the current or prior year.
227 Note 26.1 Other liabilities Group Trust 31 March 31 March 31 March 31 March 2019 2018 2019 2018 £000 £000 £000 £000 Current Deferred income: contract liabilities 5,691 4,756 5,691 4,756 Total other current liabilities 5,691 4,756 5,691 4,756
Note 26.2 Borrowings Group Trust 31 March 31 March 31 March 31 March 2019 2018 2019 2018 £000 £000 £000 £000 Current Loans from DHSC 3,026 2,958 3,026 2,958 Obligations under finance leases 398 94 398 94 Total current borrowings 3,424 3,052 3,424 3,052 Non-current Loans from DHSC 11,714 14,672 11,714 14,672 Obligations under finance leases 2,057 455 2,057 455 Total non-current borrowings 13,771 15,127 13,771 15,127
228 Note 27 Reconciliation of liabilities arising from financing activities
Loans from Finance Group DHSC leases Total £000 £000 £000 Carrying value at 1 April 2018 17,630 549 18,179 Cash movements: Financing cash flows - payments and receipts of principal (2,958) (311) (3,269) Financing cash flows - payments of interest (287) (16) (303) Non-cash movements: - Impact of implementing IFRS 9 on 1 April 2018 77 - 77 Additions - 2,218 2,218 Application of effective interest rate 278 15 293 Carrying value at 31 March 2019 14,740 2,455 17,195
The Charitable Funds do not hold any loans or finance leases, therefore financing activities relate to the Trust only.
229 Note 28 Royal United Hospitals Bath NHS Foundation Trust as a lessee Obligations under finance leases where the Trust is the lessee. Group 31 March 31 March 2019 2018 £000 £000 Gross lease liabilities 2,518 567 of which liabilities are due: - not later than one year; 416 100 years; 1,655 357 - later than five years. 447 110 Finance charges allocated to future periods (63) (18) Net lease liabilities 2,455 549 of which payable: - not later than one year; 398 94 years; 1,613 345 - later than five years. 444 110
The Charitable Funds do not hold any lease liabilities, therefore all lease liabilities relate to the Trust only
230 Note 29 Provisions for liabilities and charges analysis (Group)
Pensions: Equal Pay early (including departure Legal Agenda for Group costs claims Change) Redundancy Other Total £000 £000 £000 £000 £000 £000 At 1 April 2018 861 51 396 72 1,553 2,933 Arising during the year 82 47 - 3 288 420 Utilised during the year (80) (61) - (75) (579) (795) Reversed unused (29) - (396) - (1,043) (1,468) Unwinding of discount 8 - - - - 8 At 31 March 2019 842 37 - - 219 1,098 Expected timing of cash flows: - not later than one year; 79 37 - - 219 335 - later than one year and not later than five 763 - - - - 763 - later than five years. ------Total 842 37 - - 219 1,098
The Charitable Funds do not have any provisions, therefore the provision for the Group are those of the Trust.
Early retirement costs and injury benefit payments for staff other than directors, based on the information provided by NHS Pensions. It is certain that the amounts and timings of the cash flows are accurate for the life of the claimant.
Other Legal Claims Litigation claims against the Trust that are being handled by NHS Litigation Authority. The provision is based on the information provided by NHS Litigation Authority.
Other Other provisions have been made in relation to employment issues and performance related pay. These amounts are estimates based on known risks and salaries. It is very likely that these will be resolved in the coming year.
231 Note 29.1 Clinical negligence liabilities
At 31 March 2019, £157.3m was included in provisions of NHS Resolution in respect of clinical negligence liabilities of Royal United Hospitals Bath NHS Foundation Trust (31 March 2018: £91.3m).
liabilities Group Trust 31 March 31 March 31 March 31 March 2019 2018 2019 2018 £000 £000 £000 £000 Value of contingent liabilities NHS Resolution legal claims 37 51 37 51 Gross value of contingent liabilities 37 51 37 51 Amounts recoverable against liabilities - - - - Net value of contingent liabilities 37 51 37 51 Net value of contingent assets - - - -
Contingent liabilities are the legal claims under the liability to third parties and property expenses administered by the NHS Resolution (formerly NHS Litigation Authority). commitments Group Trust 31 March 31 March 31 March 31 March 2019 2018 2019 2018 £000 £000 £000 £000 Property, plant and equipment 14,149 24,855 14,149 24,855 Intangible assets 697 634 697 634 Total 14,846 25,489 14,846 25,489
Note 32 Other financial commitments
The Trust has no other financial commitments.
232 Note 33 Defined benefit pension schemes
Past and present employees are covered by the provisions of the two NHS Pension Schemes. Details of the ben the Schemes can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions. Both are unfunded d cover NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State for H Wales. They are not designed to be run in a way that would enable NHS bodies to identify their share of the und liabilities. Therefore, each scheme is accounted for as if it were a defined contribution scheme: the cost to the NH each scheme is taken as equal to the contributions payable to that scheme for the accounting period.
Additional pension liabilities arising from early retirements are not funded by the scheme except where the retirem due to ill-health. The full amount of the liability for the additional costs is charged to the operating expenses at th the Trust commits itself to the retirement regardless of the method of payments.
233 Note 34 Financial Instruments
Note 34.1 Financial risk management
Financial reporting standard IFRS 7 requires disclosure of the role that financial instruments have had during the creating or changing the risks a body faces in undertaking its activities. Because of the continuing service provid that the Trust has with NHS England and Clinical Commissioning Groups and the way those bodies are financed not exposed to the degree of financial risk faced by business entities. Also financial instruments play a much mo creating or changing risk than would be typical of listed companies, to which the financial reporting standards ma Trust has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by da operational activities rather than being held to change the risks facing the NHS Trust in undertaking its activities.
The Trust’s treasury management operations are carried out by the finance department, within parameters define within the Trust’s Standing Financial Instructions and policies agreed by the Board of Directors. Trust treasury ac to review by the Trust’s internal auditors.
Currency risk The Trust is principally a domestic organisation with the great majority of transactions, assets and liabilities being sterling based. Although the Trust has operations overseas, it has no establishment in other territories. The Foun therefore has low exposure to currency rate fluctuations.
Interest Rate Risk The Trust borrows from government for capital expenditure, subject to affordability. The borrowings are for 1 – 25 in line with the life of the associated assets, and interest is charged at the National Loans Fund rate, fixed for the the loan. Additionally the Trust’s cash balances are held with the Government Banking Service. The Trust therefo exposure to interest rate fluctuations.
Credit Risk Because the majority of the Trust’s income comes from contracts with other public sector bodies, it has low expo risk. The maximum exposures as at 31 March 2019 are in receivables from customers, as disclosed in the trade receivables note. These funding arrangements ensure that the Trust is not exposed to any material credit risk.
Liquidity risk The Trust’s net operating costs are incurred under agency purchase contracts with NHS England and local Clinic Commissioning Groups, which are financed from resources voted annually by Parliament. The Trust receives the of such contract income in accordance with the National Tariff Payment System (NTPS), which is intended to ma received in year to the activity delivered in that year by reference to a National / Local Tariff unit cost. The Trust r each month based on an annually agreed level of contract activity and there are periodic corrections made to ad actual income due under the contract.
The Trust presently finances its capital expenditure mainly from donations, internally generated funds and loans Department of Health and is not, therefore, exposed to significant liquidity risks in this area.
234 Note 34.2 Carrying values of financial assets IFRS 9 Financial Instruments is applied retrospectively from 1 April 2018 without restatement of comparatives. As such, comparative disclosures have been prepared under IAS 39 and the measurement categories differ to those in the current year analyses.
Held at fair Held at fair Held at value value Total Group amortised through through book cost I&E OCI value Carrying values of financial assets as at 31 £000 £000 £000 £000 March 2019 under IFRS 9 Trade and other receivables excluding non-financial assets 30,574 - - 30,574 Cash and cash equivalents 18,946 - - 18,946 Consolidated NHS Charitable fund financial assets 4,014 - 8,512 12,526 Total at 31 March 2019 53,534 - 8,512 62,046
The Charitable Fund have elected to classify equity instruments as fair value through OCI on initial recognition, the carrying value of these designated assets are £8.5m.
Assets at fair value Total Group Loans and through Held to Available- book receivables the I&E maturity for-sale value Carrying values of financial assets as at 31 £000 £000 £000 £000 £000 March 2018 under IAS 39 Trade and other receivables excluding non- financial assets 24,893 - - - 24,893 Cash and cash equivalents 32,912 - - - 32,912 Consolidated NHS Charitable fund financial assets 2,592 7,128 - - 9,720 Total at 31 March 2018 60,397 7,128 - - 67,525
Held at fair Held at fair Held at value value Total Trust amortised through through book cost I&E OCI value Carrying values of financial assets as at 31 £000 £000 £000 £000 March 2019 under IFRS 9 Trade and other receivables excluding non-financial assets 30,548 - - 30,548 Cash and cash equivalents 18,946 - - 18,946 Total at 31 March 2019 49,494 - - 49,494
Assets at fair value Total Trust Loans and through Held to Available- book receivables the I&E maturity for-sale value Carrying values of financial assets as at 31 £000 £000 £000 £000 £000 March 2018 under IAS 39 Trade and other receivables excluding non- financial assets 24,893 - - - 24,893 Cash and cash equivalents 32,912 - - - 32,912 Total at 31 March 2018 57,805 - - - 57,805
235 Note 34.3 Carrying values of financial liabilities IFRS 9 Financial Instruments is applied retrospectively from 1 April 2018 without restatement of comparatives. As such, comparative disclosures have been prepared under IAS 39 and the measurement categories differ to those in the current year analyses.
Held at fair Held at value Total amortised through book Group cost I&E value £000 £000 £000 IFRS 9 Loans from the Department of Health and Social Care 14,740 - 14,740 Obligations under finance leases 2,455 - 2,455 Trade and other payables excluding non-financial liabilities 24,118 - 24,118 Total at 31 March 2019 41,313 - 41,313
Held at fair Held at value Total amortised through book Group cost I&E value £000 £000 £000 39 Loans from the Department of Health and Social Care 17,630 - 17,630 Obligations under finance leases 549 - 549 Trade and other payables excluding non-financial liabilities 25,081 - 25,081 Total at 31 March 2018 43,260 - 43,260
Held at fair Held at value Total amortised through book Trust cost I&E value £000 £000 £000 IFRS 9 Loans from the Department of Health and Social Care 14,740 - 14,740 Obligations under finance leases 2,455 - 2,455 Trade and other payables excluding non-financial liabilities 22,217 - 22,217 Total at 31 March 2019 39,412 - 39,412
Held at fair Held at value Total amortised through book Trust cost I&E value £000 £000 £000 39 Loans from the Department of Health and Social Care 17,630 - 17,630 Obligations under finance leases 549 - 549 Trade and other payables excluding non-financial liabilities 25,081 - 25,081 Total at 31 March 2018 43,260 - 43,260
236 Note 34.4 Maturity of financial liabilities Group Trust 31 March 31 March 31 March March 2019 2018 2019 2018 £000 £000 £000 £000 In one year or less 27,542 26,194 25,641 26,194 In more than one year but not more than two years 3,356 3,297 3,356 3,297 In more than two years but not more than five years 4,808 7,013 4,808 7,013 In more than five years 5,607 6,756 5,607 6,756 Total 41,313 43,260 39,412 43,260
237 Note 35 Losses and special payments 2018/19 2017/18 Total Total number of Total value number of Total value Group and Trust cases of cases cases of cases Number £000 Number £000 Special payments Compensation under court order or legally binding arbitration award 5 - - - Ex-gratia payments 32 351 66 49 Total special payments 37 351 66 49
The Trust had one case in 2018/19 above £300k, this related to a Health & Safety Executive ruling (£337k) for which a provision was released in year.
238 Note 36 Initial application of IFRS 9
IFRS 9 Financial Instruments as interpreted and adapted by the GAM has been applied by the Trust from 1 April standard is applied retrospectively with the cumulative effect of initial application recognised as an adjustment to April 2018.
IFRS 9 replaces IAS 39 and introduces a revised approach to classification and measurement of financial assets liabilities, a new forward-looking 'expected loss' impairment model and a revised approach to hedge accounting.
Under IFRS 9, borrowings from the Department of Health and Social Care, which were previously held at historic measured on an amortised cost basis. Consequently, on 1 April 2018 borrowings increased by £77k, and trade p correspondingly reduced.
Reassessment of allowances for credit losses under the expected loss model resulted in a £0k decrease in the c receivables.
The GAM expands the definition of a contract in the context of financial instruments to include legislation and reg where this gives rise to a tax. Implementation of this adaptation on 1 April 2018 has led to the classification of rec to Injury Cost Recovery as a financial asset measured at amortised cost. The carrying value of these receivables was £0k.
Note 37 Initial application of IFRS 15 IFRS 15 Revenue from Contracts with Customers as interpreted and adapted by the GAM has been applied by t April 2018. The standard is applied retrospectively with the cumulative effect of initial application recognised as a the income and expenditure reserve on 1 April 2018.
IFRS 15 introduces a new model for the recognition of revenue from contracts with customers replacing the prev 11, IAS 18 and related Interpretations. The core principle of IFRS 15 is that an entity recognises revenue when it performance obligations through the transfer of promised goods or services to customers at an amount that refle consideration to which the entity expects to be entitled to in exchange for those goods or services.
As directed by the GAM, the Trust has applied the practical expedient offered in C7A of the standard removing th retrospectively restate any contract modifications that occurred before the date of implementation (1 April 2018).
The impact of the application of IFRS 15 in the financial statements was not material in the current reporting peri
239 Note 38 Related parties
During the year none of the Department of Health Ministers, Royal United Hospitals Bath NHS Foundation Trust board members or members of the key management staff, or parties related to any of them, has undertaken any material transactions with Royal United Hospitals Bath NHS Foundation Trust.
The Department of Health is regarded as a related party. During the 12 month period to 31 March 2019, the Trus has had a significant number of material transactions with the Department, and with other entities for which the Department is regarded as the parent Department. These entities are:
CCGs NHS Wiltshire CCG NHS Bath and North East Somerset CCG NHS Somerset CCG NHS Bristol, North Somerset and South Gloucestershire CCG NHS Gloucestershire CCG
NHS England Organisations NHS England - Core (including Provider Sustainability Funding) NHS England South West Local Office NHS England - South West Commissioning Hub NHS England South Central Local Office NHS England - Wessex Specialised Commissioning Hub
NHS Trusts and Foundation Trusts University Hospitals Bristol NHS Foundation Trust Great Western Hospitals NHS Foundation Trust North Bristol NHS Trust Salisbury NHS Foundation Trust Avon and Wiltshire Mental Health Partnership NHS Trust Somerset Partnership NHS Foundation Trust Yeovil District hospital NHS Foundation Trust Gloucestershire Hospitals NHS Foundation Trust
Other Agencies Health Education England Department Of Health (excluding PDC) Bath and North East Somerset Council Wiltshire Unitary Authority Welsh Assembly Government (including all other Welsh Health Bodies) Public Health England NHS Litigation Authority NHS Blood and Transplant (excluding Bio products Laboratory)
In addition, the Trust has had a number of material transactions with other government departments and other central and local government bodies. Most of these transactions have been with Her Majesty's Revenue and Customs in relation to Value Added Tax, National Insurance Contributions and Income Taxes.
The Trust has also received revenue and capital payments from the Royal United Hospital Bath NHS Trust Charitable Funds, for which the Trust Board acts as Corporate Trustee. The audited accounts of the Charitable Funds are available at www.ruh.nhs.uk.
The Trust is an equal partner in Wiltshire Health and Care LLP, the Trust received payment of £127k (2017-2018 £23k) in respect to the provision of Financial Services to the partnership.
240